Treatment of acute organ injury using CD39 and recombinant CD39

Abstract

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

Description

Technical Field

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

Background Art

[0002] Acute kidney injury (AKI) is an asymptomatic condition characterized by a sudden deterioration of kidney function, sometimes with a decrease or complete absence of urine output. During hospitalization, most patients, particularly critically ill patients and those undergoing major surgery, experience this syndrome. Recovery from AKI is possible, but in some patients, kidney function continues to decline further and remains chronically impaired. Some patients require at least short-term dialysis or remain dialysis-dependent with severe residual kidney dysfunction and the need for kidney transplantation.

[0003] Furthermore, during sepsis, a dysregulated host response to infection causes life-threatening multiple organ dysfunction. Sepsis is a leading cause of death and a major public health problem affecting millions of patients worldwide each year. Approximately 90% of sepsis cases are caused by bacterial infections, and 40 - 60% of septic patients experience acute kidney injury (AKI). Acute kidney injury is a common complication of sepsis. 28% of septic patients develop AKI. The onset of acute kidney injury (AKI) in patients with sepsis is associated with up to a 65% significant increase in mortality, and survivors are at risk of developing chronic kidney disease (CKD) and end-stage renal disease, imposing a significant health and economic burden on patients and society. Sepsis-associated acute kidney injury (SA-AKI) is a multifactorial syndrome with inflammatory, nephrotoxic, and ischemic disorders that occurs simultaneously with other pathophysiological responses and rapidly causes renal dysfunction. Over the past 30 years, a significant number of potential drug targets for treating sepsis and AKI have existed, and new therapies have been developed. Efforts have mainly been made to improve hemodynamics, reduce oxidative stress, and block the excessive inflammatory response, but all of them have ended in failure in clinical trials. The management of patients with SA-AKI mainly depends on antibiotics and supportive therapies including fluid resuscitation, vasoactive drugs, and renal replacement therapy.

[0004] AKI is also a frequent and severe complication of cardiopulmonary bypass surgery (CPBS), cardiac surgery-associated acute kidney injury (CSA-AKI). AKI is a new or worsening renal insufficiency characterized by a relatively rapid decrease in glomerular filtration rate (GFR), often accompanied by a decrease in urine output. AKI usually occurs within the first 7 days after the initial insult, following an episode of transient hypotension due to any cause, but can also occur after exposure to nephrotoxins or radiocontrast agents. The clinical manifestations of AKI are seen in 3 - 18% of all adult inpatients worldwide and are more common in relation to complex surgeries. By definition, AKI occurs in up to 15 - 40% of adults after CPBS. In severe AKI, renal replacement therapy is required in 1 - 5% of cases and is associated with up to 70% mortality.

[0005] Evidence from a series of studies has shown potential benefits of the conversion of extracellular ATP to adenosine in the treatment of sepsis and related organ damage. In a sepsis animal model induced by cecal ligation and puncture (CLP), treatment with apyrase, an ATPase that promotes the enzymatic degradation of extracellular ATP, decreased the concentration of extracellular ATP in peritoneal lavage and significantly reduced mortality.

[0006] Clinical studies conducted on alkaline phosphatase (ALP) in patients with SA-AKI have shown that AP improves renal function as determined by the composite endpoint of creatinine clearance, the need for RRT, and the duration of RRT. Alkaline phosphatase is an endogenous enzyme that exerts a detoxifying effect by dephosphorylating endotoxin and extracellular ATP. In a relatively large clinical trial in patients with SA-AKI (N = 301), although the study did not meet the primary evaluation criteria for short-term improvement in renal function measured by the area under the time-corrected endogenous creatinine clearance curve from day 1 to day 7, the results suggest a potential benefit in terms of mortality with AP treatment compared to placebo.

[0007] Currently, there are no approved pharmacological therapies for the treatment or prevention of AKI or SA-AKI.

Summary of the Invention

[0008] The inventors have devised a novel treatment for subjects having generally acute organ injury, particularly AKI, such as sepsis-associated acute kidney injury (SA-AKI) or cardiac surgery-associated acute kidney injury (CSA-AKI), using the recombinant CD39 and its variants defined herein, which is safe, effective, and provides a sustained therapeutic effect to patients. These novel treatments meet the long-desired requirements of clinicians and patients for a safe and effective therapy for AKI. A therapeutic approach that enhances the conversion of extracellular ATP to adenosine using the recombinant CD39 mechanism of action that hydrolyzes extracellular ATP and ADP to AMP is generally a therapeutic strategy for alleviating and suppressing acute organ injury. Due to the efficient hydrolysis of ATP and ADP, the recombinant CD39 defined herein inhibits ATP / LPS-induced IL-1β secretion and ADP- and thrombin-induced platelets in a dose-dependent manner. Inhibition of thrombin-induced platelet aggregation may be due to the release of ADP from platelet dense granules through the activation of protease-activated receptor 4 (PAR4) by thrombin-derived substances. Furthermore, the recombinant CD39 defined herein inhibits ATP / LPS-induced IL-1β release in a concentration-dependent manner. Such treatment exhibits anti-inflammatory, anti-aggregation, and tissue protection, thereby leading to improvement in renal function and reduction in mortality in subjects suffering from AKI such as SA-AKI or CSA-AKI.

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

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

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

[0012] In another embodiment, a suitable dosing schedule of recombinant CD39 as defined herein is a daily dosing schedule.

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

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

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

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

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

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

[0019] In some embodiments, the treatment plan can range from several hours to one day to several weeks and be determined by a sufficiently qualified caregiver (the treating physician).

[0020] In one embodiment, the present invention involves administering to a subject having AKI, such as SA-AKI or CSA-AKI, a recombinant CD39 as defined herein, preferably CD39*, in the range of about 0.1 mg / kg to about 10 mg / kg / treatment, preferably 1 mg / kg to 5 mg / kg, preferably in the range of about 4 - 5 mg / kg / treatment. In one embodiment, the subject is administered 4 or 5 mg / kg / treatment. In one embodiment, a subject having AKI, such as SA-AKI or CSA-AKI, receives treatment once within 48 hours after AKI, such as SA-AKI or CSA-AKI, is first diagnosed.

[0021] In some embodiments, the recombinant CD39 as defined herein, preferably CD39*, is administered in combination with one or more additional agents. In some embodiments, the one or more additional agents are steroids, metalloprotease inhibitors, serine protease inhibitors, local anesthetic emulsions, spreading factor inhibitors, antiemetics, or antibiotics.

[0022] In another aspect, the present disclosure provides a new dosing regimen of a recombinant CD39 as defined herein, preferably CD39*, that can be used in a method for treating or preventing AKI, such as SA-AKI or CSA-AKI.

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

[0024] In another aspect, the present disclosure provides a new dosing regimen of recombinant CD39, preferably CD39*, as defined herein, for use as a drug, wherein the recombinant CD39 is administered to a subject in need thereof at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. In yet another aspect, the present disclosure provides a new method of treatment using recombinant CD39, preferably CD39*, as defined herein, wherein the recombinant CD39 is administered to a subject in need thereof at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

Mode for Carrying Out the Invention

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

[0026] Embodiment: A1. Recombinant CD39 for use in treating or preventing AKI in a subject in need thereof. A2. Recombinant CD39 according to Embodiment A1, wherein the AKI is severe AKI. A3. Recombinant CD39 according to Embodiment A1, wherein at least one symptom of AKI in the subject is reduced or disappears. A4. Recombinant CD39 according to any one of the above embodiments, wherein the severity of AKI is reduced by at least one stage as defined by the modified Acute Kidney Injury Network (AKIN) criteria for serum creatinine. A5. Recombinant CD39 according to any one of Embodiments A1 to A4 for use in preventing AKI in a subject. A6. Recombinant CD39 according to any one of Embodiments A1 to A4 for use in reducing the risk of AKI. A7. Recombinant CD39 according to any one of Embodiments A1 to A4 for use in reducing the severity of AKI. Recombinant CD39 according to any one of the above embodiments, wherein the incidence of the severity of acute kidney disease evaluated by renal function and major adverse kidney events (MAKE) is reduced. Recombinant CD39 according to any one of the above embodiments, wherein the severity of SA-AKI is reduced. Recombinant CD39 according to any one of the above embodiments, wherein the progression of AKI, such as septic AKI, is blocked. Recombinant CD39 according to any one of the above embodiments, for use in improving major adverse kidney events, such as reducing kidney dysfunction. Recombinant CD39 for use in the treatment or prevention of sepsis. Recombinant CD39 according to embodiment A12, wherein the diagnosis of sepsis is carried out according to the criteria defined by The Third International Consensus. A14. Sepsis and septic shock (Sepsis-3) are - Suspected or confirmed infection, and - A rapid increase in the sequential organ failure assessment (SOFA) score over time of two or more points (excluding renal function) Recombinant CD39 according to embodiment A12 or A13, defined based on. Unless it is determined that the participant has pre-existing (acute or chronic) organ dysfunction before the onset of infection, the baseline SOFA score should be assumed to be zero. Recombinant CD39 according to any one of the above embodiments, administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. Recombinant CD39 according to any one of the above embodiments, administered at a dose of about 4 mg / kg of recombinant CD39. Recombinant CD39 according to any one of the above embodiments, administered at a dose of about 5 mg / kg of recombinant CD39. Recombinant CD39 according to any one of the above embodiments, administered by IV, such as administered by IV over about 2 hours. Recombinant CD39 according to any one of the above embodiments, which is administered within several hours after AKI is first diagnosed in the subject. Recombinant CD39 according to any one of the above embodiments, which is administered daily to the subject, for example, by intravenous infusion at a dose of about 4 or 5 mg / kg within a time interval starting from a suspected or confirmed AKI diagnosis in the subject. Recombinant CD39 according to any one of the above embodiments, which is administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours) after AKI is first diagnosed in the subject. Recombinant CD39 according to any one of the above embodiments, which is administered within about 24 hours or as soon as possible after AKI or sepsis is first diagnosed. Recombinant CD39 according to any one of the above embodiments, which is administered within several hours after sepsis is first diagnosed in the subject. Recombinant CD39 according to any one of the above embodiments, which is administered daily to the subject, for example, by intravenous infusion at a dose of about 4 or 5 mg / kg within a time interval starting from a suspected or confirmed sepsis diagnosis in the subject. Recombinant CD39 according to any one of the above embodiments, which is administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours) after sepsis is first diagnosed in the subject. Recombinant CD39 according to any one of the above embodiments, which has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21. Recombinant CD39 according to any one of the above embodiments, which has the amino acid sequence of SEQ ID NO: 21. Recombinant CD39 according to any one of the above embodiments, which is administered to the subject as a monotherapy. Recombinant CD39 according to any one of the above embodiments, which is co-administered with an additional therapeutic agent. Recombinant CD39 according to any one of the above embodiments, co-administered with an additional therapeutic agent selected from the group consisting of a steroid, a metalloproteinase inhibitor, a serine protease inhibitor, a local anesthetic emulsion, a diffusion factor inhibitor, an antiemetic, or an antibiotic. Recombinant CD39 according to any one of the above embodiments, wherein the AKI is SA-AKI. Recombinant CD39 according to any one of the above embodiments, wherein the AKI is cardiac surgery-related acute kidney injury (CSA-AKI). Recombinant CD39 according to any one of the above embodiments, used in a method for preventing or treating one or more symptoms associated with AKI. Recombinant CD39 for use as a drug, administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. Recombinant CD39 for use in the treatment or prevention of tissue damage, administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. Recombinant CD39 for use in the treatment or prevention of tissue damage, wherein the tissue damage is acute brain injury (stroke); acute multiple organ failure; delayed graft function after transplantation of the kidney or other solid organs; burn injury; radiation injury; trauma and / or hypoxia, such as acute injury caused by acute respiratory distress syndrome (ARDS) or lung injury; acute kidney injury, such as acute kidney injury secondary to thoracic surgery (e.g., aortic valve replacement, coronary artery bypass surgery) or sepsis or rhabdomyolysis or the toxic effects of antibiotics or other drugs, and the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. Recombinant CD39 for use in the treatment of a combination often referred to as delayed graft function (DGF), acute respiratory distress syndrome (ARDS), acute myocardial infarction (AMI), traumatic brain injury (TBI) / acute ischemic stroke (AIS), ischemia-reperfusion injury (IRI) or multiple organ failure (MOF), the recombinant CD39 being administered at a dose of from about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. Recombinant CD39 for use according to embodiment A36 or A37, administered at a dose of about 1 mg / kg of recombinant CD39. Recombinant CD39 for use according to embodiment A36 or A37, administered at a dose of about 2 mg / kg of recombinant CD39. Recombinant CD39 for use according to embodiment A36 or A37, administered at a dose of about 4 mg / kg of recombinant CD39. Recombinant CD39 for use according to embodiment A36 or A37, administered at a dose of about 5 mg / kg of recombinant CD39. Recombinant CD39 for use according to embodiment A36 or A37, administered by IV, such as by IV administration over about 2 hours. Recombinant CD39 according to any one of the above embodiments, comprising the amino acid sequence of SEQ ID NO: 2. B1. A method of performing in a subject, particularly a subject in need thereof, the treatment or prevention of AKI, the method comprising administering recombinant CD39, typically in a therapeutically effective amount. B2. The method according to embodiment B1, wherein the AKI is severe AKI. B3. The method according to embodiment B1, wherein at least one symptom of AKI in the subject is reduced or eliminated. B4. The method according to any one of the above embodiments B1 - B3, wherein the severity of AKI is reduced by at least one stage as defined by the modified Acute Kidney Injury Network (AKIN) criteria for serum creatinine. B5. The method according to any one of the above embodiments B1 - B4, wherein the risk of AKI is reduced. A method according to any one of the above embodiments B1 - B4, in which the severity of B6.AKI is reduced. B7. A method according to any one of the above embodiments B1 - B4, in which the incidence of the severity of acute kidney disease evaluated by renal function and major adverse kidney events (MAKE) is reduced. B8. A method according to any one of the above embodiments B1 - B4, in which the progression of AKI, for example, septic AKI, is blocked. B9. A method according to any one of the above embodiments B1 - B8, in which one or more major adverse kidney events are improved, for example, renal dysfunction is reduced. B10. A method for treating or preventing sepsis, particularly in a subject in need thereof, comprising administering recombinant CD39 typically in a therapeutically effective amount. B11. A method according to embodiment B10, in which the diagnosis of sepsis is carried out according to the criteria defined by The Third International Consensus. B12. Sepsis and septic shock (sepsis - 3) are - Suspected or confirmed infection, and - A rapid increase in the sequential organ failure assessment (SOFA) score over time of two or more points (excluding renal function) Defined based on, a method according to embodiment B10 or B11. Unless it has been determined that the participant has an existing (acute or chronic) organ dysfunction prior to the onset of infection, the baseline SOFA score should be assumed to be zero. B13. A method according to any one of the above embodiments B1 - B12, in which recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. B14. A method according to any one of the above embodiments B1 - B13, in which recombinant CD39 is administered IV, for example, over about 2 hours. After AKI or sepsis is first diagnosed in the subject, within several hours, for example, within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours) after AKI is first diagnosed in the subject, the method according to any one of the above embodiments B1 to B14 is administered. B16. The method according to any one of the above embodiments B1 to B15, wherein recombinant CD39 is administered to the subject daily, for example, by intravenous administration, at a dose of about 4 or 5 mg / kg by infusion within the time interval starting from a suspected or confirmed AKI diagnosis or sepsis diagnosis in the subject. B17. The method according to any one of the above embodiments B1 to B16, wherein recombinant CD39 has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21. B18. The method according to any one of the above embodiments B1 to B17, wherein recombinant CD39 has the amino acid sequence of SEQ ID NO: 21. B19. The method according to any one of the above embodiments B1 to B18, wherein recombinant CD39 is administered to the subject as a monotherapy. B20. The method according to any one of the above embodiments B1 to B18, wherein recombinant CD39 is co-administered with an additional therapeutic agent. B21. The method according to embodiment B20, wherein recombinant CD39 is co-administered with an additional therapeutic agent selected from the group consisting of steroids, metalloproteinase inhibitors, serine protease inhibitors, local anesthetic emulsions, diffusion factor inhibitors, antiemetics, or antibiotics. B22. The method according to any one of the above embodiments B1 to B21, wherein AKI is SA-AKI or cardiac surgery-related acute kidney injury (CSA-AKI). B23. A therapeutic method using recombinant CD39, wherein recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. A method for treating or preventing tissue damage using recombinant CD39, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. A method for treating or preventing tissue damage using recombinant CD39, wherein the tissue damage is acute brain injury (stroke); acute multiple organ failure; delayed graft function after transplantation of the kidney or other solid organs; burn injury; radiation injury; trauma and / or hypoxia, such as acute injury caused by acute respiratory distress syndrome (ARDS) or lung injury; acute kidney injury, such as acute kidney injury secondary to thoracic surgery (e.g., aortic valve replacement, coronary artery bypass surgery) or sepsis or rhabdomyolysis or the toxic effects of antibiotics or other drugs, and the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. A method for treating a combination, often also referred to as delayed graft function (DGF), acute respiratory distress syndrome (ARDS), acute myocardial infarction (AMI), traumatic brain injury (TBI) / acute ischemic stroke (AIS), ischemia-reperfusion injury (IRI) or multiple organ failure (MOF), using recombinant CD39, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, such as a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. A method according to any one of the above embodiments B1 - B26, wherein the recombinant CD39 comprises the amino acid sequence of SEQ ID NO: 21.

[0027] Definitions As used herein, the term "CD39" refers to human protein CD39 (cluster of differentiation 39), also known as ectonucleoside triphosphate diphosphohydrolase 1 (NTPDase1 or Ecto-ATPDase1). CD39 is an ectonucleotidase present on the cell surface having a catalytic site on the extracellular surface that catalyzes the hydrolysis of the γ and β phosphate residues of tri- and diphosphonucleosides to monophosphonucleoside derivatives. Human CD39 has, in particular, the amino acid sequence of SEQ ID NO: 22 and / or is represented by UniProt entry P49961.

[0028] "Variant of CD39" means a protein derived from human CD39 having an amino acid sequence that is at least 60% identical to human CD39 over the full length of human CD39. In certain embodiments, the variant of CD39 consists of only the extracellular domain of human CD39 or a portion thereof (amino acids 38 to 478 of SEQ ID NO: 22). In particular, the variant of CD39 has an amino acid sequence that is at least identical to the extracellular domain of human CD39 over the full length of amino acids 38 to 478 of human CD39. In particular, the CD39 variant is a soluble variant, i.e., a variant lacking the transmembrane domain of human CD39 and its membrane anchor. In certain embodiments, the variant has an N-terminal deletion of 30 to 50 amino acids, a C-terminal deletion of 20 to 40 amino acids, and / or a central deletion of 10 to 15 amino acids compared to human CD39. Furthermore, the variant may contain up to five point mutations compared to human CD39. Certain variants of CD39 are disclosed in WO 2020 / 016804 pamphlet. In particular, the human recombinant CD39 variant has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

[0029] "Recombinant CD39" particularly means a human recombinant CD39 variant having an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

[0030] The term "about" with respect to a numerical value x means, for example, + / - 10%. When used before a numerical range or a list of numbers, the term "about" applies to each of the consecutive numbers, for example, the phrase "about 1 - 5" should be interpreted as "about 1 - about 5", or the phrase "about 1, 2, 3, 4" should be interpreted as "about 1, about 2, about 3, about 4, etc."

[0031] The word "substantially" does not exclude "completely", for example, a composition "substantially free of" Y may in some cases be completely free of Y. If necessary, the word "substantially" may be omitted from the definitions of the present disclosure.

[0032] A subject "in need of" treatment as used herein is one for which such treatment would result in a benefit in terms of biology, medicine, or quality of life.

[0033] The term "pharmaceutically acceptable" means a non-toxic substance that does not interfere with the effectiveness of the biological activity of the active ingredient.

[0034] As used herein, the term "treatment" or "treating" is defined as the application or administration of apyrase according to the present invention to a subject or the application or administration of a pharmaceutical composition comprising the recombinant CD39 to a subject or to an isolated tissue or cell line from the subject when the subject has tissue damage, symptoms associated with tissue damage, and the purpose is to reduce, recover, or improve the tissue damage or the symptoms associated with tissue damage, particularly by reducing the level of extracellular ATP.

[0035] When a subject has tissue damage, symptoms associated with tissue damage, and the purpose is to reduce, recover, or improve the tissue damage or the symptoms associated with tissue damage, particularly by reducing the level of extracellular ATP, "treatment" is also intended to mean the application or administration of a pharmaceutical composition comprising the recombinant CD39 to the subject or the application or administration of a pharmaceutical composition comprising the apyrase of the present invention to an isolated tissue or cell line from the subject.

[0036] The term "prevent" or "preventing" means prophylaxis or preventive treatment and relates to delaying or preventing the onset of a disease, disorder and / or associated symptoms.

[0037] As used herein, the term "administer" or "administering" a subject compound means providing the compounds of the invention and their prodrugs to a subject in need of treatment. Administration "in combination with" one or more additional therapeutic agents means simultaneous (concurrent) administration and sequential administration in any order and by any route of administration.

[0038] As used herein, "therapeutically effective dose" means a dose (amount) of recombinant CD39 that is effective when administered to a patient (such as a human) in a single or multiple doses to treat, prevent, prevent the onset of, cure, delay, reduce the severity of, improve at least one symptom of a disease or recurrent disease, or extend the survival time of a patient beyond the time expected in the absence of such treatment. When applied to an individual active ingredient administered alone (e.g., recombinant CD39), the term means that ingredient alone. When applied to a combination, the term means the combined dose or amount of the active ingredients that results in a therapeutic effect, whether administered continuously or simultaneously.

[0039] The phrase "treatment regimen" means a plan used to treat a disease, e.g., an administration protocol used during the treatment of AKI, SA-AKI or CSA-AKI.

[0040] The phrase "means of administration" is used to denote, but is not limited to, prefilled syringes, vials and syringes, pen injectors, self-injectors, intravenous drip bags, pumps, patch pumps, etc., devices available for systemic administration of a drug to a patient. Using such devices, a patient may self-administer the drug (i.e., administer the drug for themselves) or a physician may administer the drug.

[0041] The determination of AKI, for example severe AKI, is based on the staging system described in the KDIGO guidelines for acute kidney injury. In this classification system, AKI is divided into three levels based on the degree of sCr assessment, in parallel with the degree and duration of oliguria. Patients are classified based on the worst finding (either sCr or oliguria). The three stages of AKI are classified in the following table.

[0042]

Table 1

[0043] The diagnosis of sepsis can be made, for example, in accordance with the criteria defined by The Third International Consensus on sepsis and septic shock (Sepsis-3), together with an additional diagnosis of AKI (stage 1 or above using the criteria based on KDIGO serum creatinine).

[0044] The term "cardiac surgery" means a non-emergency open-chest cardiopulmonary bypass (CPB) major surgery with an expected CPB time exceeding 1 hour, defined as any of the following options: a. Combined coronary artery bypass graft (CABG) surgery and surgery of one or more heart valves (valve surgery) b. Surgery of multiple heart valves (valve surgery) c. Surgery of the aortic root or ascending part of the aorta or surgery combined with the aortic valve d. Surgery of the aortic root or ascending part of the aorta combined with CABG and / or valve surgery and is used for this purpose.

[0045] "Sequential Organ Failure Assessment" (SOFA) score: The SOFA score was developed to assess the acute morbidity of important diseases at the population level and has been widely validated as a tool for this purpose across a range of healthcare settings and environments. Following the development of the new definition, it is currently used as an important criterion in the diagnosis of sepsis syndrome at the individual patient level. The score is calculated daily for ICU admissions and for each subsequent 24-hour period. It consists of six criteria that reflect the function of specific organ systems (respiratory, cardiovascular, renal, neurological, hepatic, and hematological), and a score from 0 to 4 points is assigned.

[0046] The score ranges from 0 to 24, and a higher score indicates more severe organ failure.

[0047] The SOFA score is applied in the clinical and research fields.

[0048] In relation to randomized controlled trials, 25 studies were identified from a meta-analysis where the change in SOFA score from baseline or maximum value up to the defined time point was used, and a strong association between the change in SOFA and mortality was revealed, with 32% of the confirmed mortality results being explained by the delta SOFA score. From this association of the SOFA score at admission and the SOFA score during the ICU admission period with longer-term outcomes, the use of delta SOFA led to the EMA approval that it is a valid surrogate endpoint in exploratory clinical trials of participants with sepsis.

[0049] "Acute Physiology and Chronic Health Evaluation" (APACHE-II) score: The APACHE-II score is a disease severity classification system for the evaluation of critically ill patients. It is applied within 24 hours of a patient's admission to the ICU or intermediate intensive care unit / HDU. An integer score from 0 to 71 is calculated by computer based on several measurements. In ICU patients, the higher the score, the greater the disease severity and the higher the risk of death.

[0050] "Renal replacement therapy" (RRT): Initiation of RRT is recommended by meeting at least one of the following criteria: 1. Anuria (very little urine output over 6 hours) 2. Severe oliguria (urine output < 200 mL over 12 hours) 3. Hyperkalemia (potassium concentration > 6.5 mmol / L) 4. Severe metabolic acidosis (pH < 7.2 despite normal partial pressure of carbon dioxide in arterial blood or low PaCO2) 5. Fluid volume overload 6. Marked azotemia (urea concentration > 30 mmol / L (> 84 mg / dL) or creatinine concentration > 300 μmol / L (> 3.4 mg / dL)) 7. Clinical complications of uremia (e.g., brain disorder, pericarditis, neuropathy).

[0051] "Major adverse kidney events" (MAKE) is a composite endpoint that includes death, the need for RRT, and deterioration of renal function (a decrease in eGFR of 25% or more from the reference baseline). It can be evaluated at defined intervals / time points and is increasingly recognized as an important participant-level outcome from studies in critically ill participants. The incidence of MAKE is calculated at 30, 60, and 90 days. The number of participants in the composite endpoint MAKE, where MAKE is defined as a participant having death, RRT, or a decrease in eGFR of 25% or more from the reference baseline. eGFR is calculated using the CKD-EPI formula without including ethnic factors.

[0052] In additional preferred embodiments, the disclosure relates to the use of recombinant CD39 according to the invention for the treatment of sepsis-associated acute kidney injury, SA-AKI.

[0053] In additional preferred embodiments, the disclosure relates to the use of recombinant CD39 according to the invention for the treatment of cardiac surgery-associated acute kidney injury, CSA-AKI.

[0054] Exemplary and non-limiting embodiments of the methods described in this disclosure are provided below. [Examples]

[0055] Example 1: Therapeutic composition Therapeutic proteins can typically be formulated as lyophilized products that are in an aqueous state ready for administration or reconstituted with a suitable diluent prior to administration. The protein can be formulated as a lyophilized product or an aqueous composition, for example, in a prefilled syringe.

[0056] Appropriate formulation can provide an aqueous pharmaceutical composition or a lyophilized product that can be reconstituted to obtain a solution having a high concentration of the therapeutic protein active ingredient and a low level of protein aggregation for delivery to a patient. High concentrations of protein are useful because the amount (dose) that must be delivered to the patient is reduced. Reducing the administration volume minimizes the time required to deliver a fixed dose to the patient. The aqueous compositions of the present invention containing protein at high concentration are particularly suitable for subcutaneous administration.

[0057] Accordingly, the present invention provides an aqueous pharmaceutical composition containing a therapeutic protein suitable for administration to a subject, for example, subcutaneous administration.

[0058] When combined with a pharmaceutically acceptable carrier, the therapeutic protein can be used as a pharmaceutical composition. Such compositions can contain, in addition to the therapeutic protein, carriers, various diluents, fillers, salts, buffers, stabilizers, solubilizing agents, and other substances well known in the art. The properties of the carrier will vary depending on the route of administration. The pharmaceutical compositions used in the disclosed methods can also contain additional therapeutic agents for the treatment of specific targeted diseases.

[0059] Since the indications for use according to the present invention (for example, the treatment of SA-AKI) require immediate treatment, they can be administered as an intravenous formulation or a liquid formulation rather than an oral administration.

[0060] Recombinant CD39 with accession number 21 (hereinafter in “CD39*”) is a genetically engineered, highly effective, soluble and stabilized human recombinant CD39 enzyme. The enzyme hydrolyzes extracellular ATP and ADP to adenosine monophosphate, which is the rate-limiting step in the conversion of extracellular ATP to adenosine. AMP is further catalyzed to adenosine by ecto-5'-nucleotidase CD73. The enzymatic activities of CD39 and CD7 play a strategic role in calibrating the duration, magnitude and chemical nature of purinergic signals transmitted to immune cells and driving the shift from an ATP-driven pro-inflammatory environment to an adenosine-induced anti-inflammatory environment. It is increasingly recognized that by rebalancing this equilibrium, the course and outcome of some pathophysiological events such as SA-AKI can be altered.

[0061] Exemplary methods for obtaining specific variants of CD39, recombinant CD39, such as CD39*, are disclosed in WO 2020 / 016804 pamphlet.

[0062] Example 2. Evaluation in preclinical trials CD39* has been extensively studied in preclinical models. In human whole blood, CD39* inhibited ATP / lipopolysaccharide (LPS)-induced IL-1β secretion and ADP-induced platelet aggregation in a dose-dependent manner. CD39* has been demonstrated to be beneficial in preclinical models of acute organ injury, such as a mouse model of ischemia-reperfusion-induced AKI, and CD39* protected renal function in a dose-dependent manner. The protection can be shown in terms of kidney structure, kidney inflammation and acute tubular necrosis, which are also prominent features of human AKI pathophysiology (results not shown).

[0063] Furthermore, general biomarkers of kidney injury, function and repair in kidney tissue from animals that received AKI were normalized to normal levels using CD39* treatment.

[0064] Biomarkers of target engagement in the urine of animals after AKI and proximal pharmacodynamic extracellular ATP and ADP are reduced in a dose-dependent manner, and extracellular AMP and adenosine are increased in a dose-dependent manner.

[0065] The in vitro efficacy of CD39* in whole blood (WB) assays (LPS / ATP-induced IL-1β release and ADP-induced platelet aggregation) was demonstrated to be equivalent in rats, minipigs, and humans. Due to the similarity in pharmacology across species, it was possible to predict and explore the exposure ranges expected to be safe in light of animal safety and pharmacology data and the predicted therapeutic doses to be reached. From these PD whole blood assays, it became clear that for humans, the in vitro IC90 is approximately 1.66 - 2.66 μg / mL.

[0066] Example 3. Phase I, randomized, placebo-controlled, participant-blinded trial in healthy volunteers This trial is a Phase I, randomized, placebo-controlled, participant-blinded trial in healthy volunteers. In this trial, single IV doses of CD39* (0.1, 0.3, 1.0, and 2.0 mg / kg and 4.0 mg / kg) are administered to healthy participants as 2-hour infusions.

[0067] Administration of CD39* or placebo as single IV infusions at 0.1, 0.3, 1.0, and 2.0 mg / kg and 4.0 mg / kg was well tolerated, and no safety signals regarding the investigational medicinal product (IMP) were shown.

[0068] CD39* was safe, with no immunogenicity findings and was well tolerated.

[0069] The PK results were in complete agreement with the pre-predicted CD39* serum concentrations.

[0070] In CD39* - treated subjects, dose - dependent and reversible inhibition of (i) in vitro ADP - induced platelet aggregation and (ii) in vitro LPS / ATP - induced IL - 1β release, resulting in in vitro IC90s of 0.25 and 7.8 μg / mL for inhibition of platelet aggregation and IL - 1β release, respectively, are demonstrated from markers of pathway engagement.

[0071] Doses of CD39* above 0.1 mg / kg induced a dose - dependent and reversible decrease in free inorganic pyrophosphate (PPi) levels, reaching maximum effect within hours after administration.

[0072] Dose - proportional behavior was demonstrated for this dose range from the exposure determined by Cmax and AUCinf. When increasing from 0.1 - 0.3 mg / kg, 1.0 mg / kg, and 2.0 mg / kg respectively, with the dose increasing 3 - fold, 10 - fold, and 20 - fold, the mean Cmax increased 3 - fold, 12 - fold, and 24 - fold, and the mean AUCinf increased 3 - fold, 11 - fold, and 17 - fold.

[0073] Dose - proportionality was also demonstrated by evaluating the correlation between dose and Cmax and the correlation between dose and AUC using a power model.

[0074] CD39* exposure was investigated across SAD cohorts 1 - 4 (0.1, 0.3, 1.0, and 2.0 mg / kg intravenous) in human skin by quantifying CD39* in interstitial fluid collected by suction blisters at 24 and 168 hours post - administration. CD39* exposure in interstitial fluid increased fairly dose - proportionally. By increasing the dose 3 - fold, 10 - fold, and 20 - fold, the mean interstitial fluid concentration increased 3 - fold, 10 - fold, and 33 - fold at 24 hours post - administration and 3 - fold, 9 - fold, and 18 - fold at 168 hours post - administration, respectively.

[0075] From the results of this study, CD39* was found to be safe and well - tolerated.

[0076] Example 4. A method for treating sepsis-related acute kidney injury, the method comprising administering recombinant CD39* to a subject in need thereof in a therapeutically effective dose This is a multi-center, participant- and investigator-blinded, randomized, placebo-controlled trial to characterize the PK / PD profile in adult inpatients with a diagnosis of sepsis and acute kidney injury (AKI) and to evaluate the safety and efficacy of the human recombinant CD39 enzyme, CD39*. Approximately 20 participants will be randomized in the trial. The trial consists of a screening period (up to 48 hours), a treatment period (day 1), and a post-treatment period (days 2 to 90).

[0077] Screening is conducted during hospitalization in the intensive care unit (ICU) or intermediate intensive care unit / high-dependency unit (HDU), and potential participants undergo screening to assess the presence of sepsis and AKI based on the sequential organ failure assessment (SOFA) and Kidney Disease: Improving Global Outcomes (KDIGO) scores over time.

[0078] Participants are randomly assigned to receive either 2 mg / kg of CD39* or placebo using a 3:1 allocation ratio (CD39*:placebo). The single dose of investigational treatment is administered by 2-hour IV infusion at the randomized visit in a participant- and investigator-blinded manner. Investigational treatment must be administered within 48 hours after SA-AKI is first diagnosed, but ideally as soon as possible. Two PK samples are collected on day 1, one before investigational treatment and the other immediately after completion of the IV infusion (within 15 minutes), and additional samples are collected on days 2, 3, 5, 8, 14, 30, 60, and 90, optimally always at the same time of day as the time point when CD39* administration started on day 1. All participants are followed up for a total period of 90 days.

[0079] Safety is monitored throughout the course of the trial. All adverse events (AEs) and serious adverse events (SAEs) are collected and reported according to standard processes and local regulations.

[0080] The exposure expected systemically and in relevant tissues at 2 mg / kg is thought to inhibit purinergic signaling and provide beneficial pharmacological effects. The total exposure (AUC inf ) following a single dose of 2 mg / kg in humans is approximately 10.4-fold lower compared to the NOAEL total exposure from 4 IV administrations of CD39 * 10 mg / kg administered every 4 days (q4d) in minipig studies (exposure margin is 2.6-fold, compared to AUC tau,ss from the 4th administration in steady-state minipigs), and C max shows a margin of 7-fold over the NOAEL exposure. Participants will be followed for the entire 90-day period.

[0081] Participants eligible for inclusion in this trial must meet all of the following criteria in the screening assessment (Day 1), unless otherwise specifically designated by randomization: 1. A signed informed consent must be obtained prior to participating in the trial. 2. Aged 18 years or older and 85 years or younger. 3. Hospitalization in an ICU or intermediate intensive care unit / HDU. 4. The following: · Suspected or confirmed infection · A diagnosis according to the criteria defined by The Third International Consensus Definitions for sepsis and septic shock (Sepsis-3) based on a SOFA score of 2 or more (excluding renal function). 5. A diagnosis of AKI stage 1 or higher according to the following criteria at the time of randomization: · An absolute increase in serum or plasma creatinine (CR) of 0.3 mg / dL or more (26.5 μmol / L or more) within 48 hours or within the previous 48 hours presumed to have occurred, compared to the reference creatinine baseline. · For hospital-acquired AKI, the stable serum creatinine obtained in the hospital prior to AKI serves as the reference baseline, otherwise, in the following order of priority: 1. The average value within 3 months of hospitalization. If not available: 1. The average value within 3 months of hospitalization. If not available: 2. Mean value during the 3 to 6 months before admission. If not available: 3. Value at the time of admission should be used as the baseline serum creatinine.

[0082] Unless otherwise specified at the time of randomization (day 1), participants who meet any of the following criteria in the screening assessment are not eligible for inclusion in this trial. 1. Expected not to survive for 24 hours. 2. Expected not to survive for 30 days due to conditions other than SA-AKI. 3. History of CKD with a recorded estimated GFR < 45 ml / min before the onset of AKI. 4. Receiving RRT within 24 hours of admission or having a decision to initiate RRT. 5. Body weight less than 40 kg or exceeding 125 kg. 6. Having life-sustaining restrictions (e.g., do not resuscitate, do not dialyze, do not intubate). 7. AKI diagnosis according to the AKI inclusion criteria for a period exceeding 48 hours before administration of the investigational drug. 8. Presence of AKI for a period exceeding 48 hours before administration of the investigational drug suggested by clinical signs. For example, prolonged anuria or severe renal insufficiency (e.g., serum creatinine > 4 mg / dL) on admission without a history of CKD. 9. Evidence of recovery from AKI based on the clinical judgment of the investigator before randomization. 10. AKI is likely to be caused by causes other than sepsis, such as nephrotoxic drugs (non-steroidal anti-inflammatory drugs (NSAIDs), contrast agents, aminoglycosides), other conditions (e.g., heart failure, liver failure, acute abdominal aortic aneurysm, dissection, renal artery stenosis), or urinary tract obstruction. 11. History of recorded (proven by biopsy) or suspected acute or subacute renal diseases, such as rapidly progressive glomerulonephritis (RPGN) and acute interstitial nephritis (AIN). 12. Patients after nephrectomy. 13. Patients on combination therapy with two antiplatelet drugs. 14. Patients who are thrombocytopenic at the time of screening (platelet count < 100,000 microliters) or who, in the opinion of the trial implementer, are at high risk of bleeding. 15. Immunosuppressed patients: · History of immunodeficiency disease or known positive HIV test. · Patients who are receiving immunosuppressive drug treatment or who are receiving chronic high-dose steroid administration (high-dose therapy exceeding 2 weeks of treatment) equivalent to prednisone / prednisolone 0.5 mg / kg / day, such as solid organ transplant patients. Patients with septic shock treated with hydrocortisone (e.g., 3 × 100 mg) can be included. 16. For active hepatitis B or C infection, positive hepatitis B virus (HBV) or hepatitis C virus (HCV) serology, patients with active hepatitis ((a) abnormal liver enzymes (alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), ALP > 3 × upper limit of normal (ULN)) or (b) as defined) or a Child-Pugh score of 10 - 15 points (class C), confirmed by progressive chronic liver disease. 17. Acute pancreatitis with an unknown source of infection. 18. Active hematopoietic tumors (previously treated hematopoietic tumors that are not actively treated are acceptable). 19. Burns requiring ICU treatment. 20. Septicemia caused by confirmed COVID-19. 21. Use of other investigational drugs within 5 times the half-life from registration, within 30 days (e.g., for small molecules) / or until the expected pharmacodynamic effect returns to baseline (e.g., for biologic agents), whichever is the longer period or, if required by regional regulations, a longer period. 22. History of hypersensitivity to the investigational treatment or its excipients or drugs of a similar chemical class. 23. Any medical condition that, in the judgment of the trial implementer, may significantly increase the risk of participant safety by participating in this trial. 24. Women who are positive for pregnancy test, pregnant, or breastfeeding. 25. Women who are potentially pregnant, defined as all women who can physiologically become pregnant, unless they are using a highly effective method of contraception, during the period of receiving investigational treatment and for 38 days after discontinuation of dosing. Highly effective methods of contraception include: · Total abstinence (if this is consistent with the participant's preferred and usual lifestyle). Periodic abstinence (e.g., calendar method, ovulation method, symptothermal method, post-ovulation method) and withdrawal, which is not an acceptable method of contraception. · Female sterilization (with or without hysterectomy, having had bilateral surgical oophorectomy), total hysterectomy, bilateral tubal ligation at least 6 weeks prior to administration of the investigational drug. In the case of oophorectomy only, only if the woman's reproductive status has been confirmed by hormonal level assessment during follow-up. · Male sterilization (at least 6 months prior to screening). For female participants in the trial, the vasectomized male partner should be the participant's only partner. · Use of oral (estrogen and progesterone), injectable or implantable hormonal methods of contraception or intrauterine devices (IUDs) or intrauterine systems (IUSs) or other forms of hormonal contraception with comparable effectiveness (failure rate < 1%), such as hormonal contraceptive vaginal rings or transdermal hormonal contraception methods. The investigational treatment drug is administered as a 2-hour (approximate) IV infusion using a perfusor syringe at the clinical site by the study staff according to the specified study procedure.

[0083] Example 5. A randomized, multi-center, placebo-controlled, participant and investigator blinded trial to evaluate the safety, tolerability, and efficacy of a single intravenous injection of CD39* in adult patients at risk of acute kidney injury after cardiac surgery This is an unvalidated, randomized, multi-center, placebo-controlled, participant and investigator blinded trial. Approximately 120 adult patients at risk of acute kidney injury after cardiac surgery will be enrolled in the trial.

[0084] There are two groups in the trial. · Placebo · CD39 * 4 mg / kg

[0085] Participants enrolled in this trial are managed according to current medical and surgical standards of care and according to the facility's standard procedures. This trial consists of a pre-operative period (screening visit), a treatment period (day 1), and a follow-up period (days 2 - 90). Participants are followed up at the hospital on days 2, 3, 4, 5, 6, and 8 (or at home / rehabilitation facility if discharged earlier than day 8), and then followed up as outpatients until the end of the trial (visits on days 30 and 90).

[0086] On day 1, participants undergo cardiac surgery. Randomization is performed if the cardiopulmonary bypass time is confirmed to be 60 minutes or more. Participants are stratified according to the following factors: eGFR >= 30 mL / min / 1.73m2 vs eGFR < 30 mL / min / 1.73m2. Once the wound is closed and no continuous bleeding is confirmed, participants receive a single dose of CD39* or placebo. Administration should start as soon as possible after wound closure and no later than 60 minutes after wound closure.

[0087] In this trial, patients are administered the investigational drug or placebo at a dose of 4 mg / kg by 2-hour intravenous infusion in a double-blind manner. The 4 mg / kg dose is the highest safe dose tested in healthy volunteers, and the exposure expected systemically and in relevant tissues is thought to inhibit purinergic signaling and provide beneficial pharmacological effects. The total exposure (AUCinf) of a single 4 mg / kg dose in humans is approximately 5.2-fold lower compared to the NOAEL total exposure from 4 IV administrations of CD39* 10 mg / kg administered every 4 days (q4d) in a 2-week minipig study (exposure margin is 1.3-fold, compared to the AUC from the 4th administration in minipigs), and Cmax shows a 3.5-fold margin over the NOAEL exposure. Participants are followed up for the entire 90-day period.

[0088] Participants eligible for inclusion in this trial must meet all of the following criteria: 1. Prior to participating in the clinical trial, a signed informed consent must be obtained. 2. Participants must be able to communicate fully with the clinical trial implementer and understand and comply with the requirements of the clinical trial. 3. Male and female patients aged 45 years or older at the screening time 4. Participants must weigh at least 50 kg and at most 150 kg and have a body mass index (BMI) of less than 40 to participate in the clinical trial. BMI = weight (kg) / [height (m)] 2 5. At the screening time, vital signs (systolic blood pressure, diastolic blood pressure, and pulse rate) are evaluated in the sitting position. The sitting vital signs should be within the following ranges: a. Oral body temperature 35.0 - 37.5 °C b. Blood pressure (systolic blood pressure 100 - 160 mmHg, diastolic blood pressure < 100 mmHg) c. Stable pulse rate (50 - 100 beats / min) without or with medication according to the evaluation of the clinical trial implementer. If the vital signs are outside these ranges, the clinical trial implementer can obtain two additional readings so that up to three consecutive evaluations are performed. At least the last reading must be within the ranges shown above for the participant to be eligible. 6. Using the standard assay methodology, a known increase of SCr ≥ -25% at the screening visit compared to the value recorded by the laboratory in the local area six weeks or less before. 7. eGFR < 60 mL / min / 1.73 m2 at the screening time (stages 3A or above of CKD) (calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD - EPI 2021) equation). 8. The following options: a. Combined coronary artery bypass graft (CABG) surgery and surgery of one or more heart valves (valve surgery) b. Surgery of multiple heart valves (valve surgery) c. Surgery of the aortic root or ascending part of the aorta or surgery combined with the aortic valve Surgery on the aortic root or ascending part of the aorta combined with CABG and / or valve surgery Non-emergency open-chest cardiopulmonary bypass (CPB) surgery with an expected CPB time > 1 hour, as defined by any of the following: Note 1: In the case of CABG only or single-valve surgery, the participant must have at least one additional risk factor for AKI: i. Drug-dependent diabetes defined as type 1 or 2 prior to admission for cardiac surgery. ii. Proteinuria defined as urine albumin / creatinine ratio > 300 mg / g (30 mg / mmol) or urine albumin excretion > 300 mg / 24 hours at the screening time point. iii. Age ≥ 70 years at the screening time point. iv. History of congestive heart failure requiring hospitalization. Note 2: Minimally invasive cardiac surgery (MICS) performed by mini-thoracotomy that meets the definition of open-chest intervention, and patients undergoing MICS can be enrolled if the CPB time > 1 hour and inclusion criterion number 8 is met. Note 3: Transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR) is only permitted when performed in combination with a surgery defined under inclusion criterion 8.

[0089] Participants who meet any of the following criteria are not eligible for inclusion in this trial. 1. Have an eGFR < 15 mL / min / 1.73 m2 (calculated using the CKD-EPI 2021 formula) at screening. 2. Are currently receiving renal replacement therapy. 3. Any of the following: - A history of bleeding disorder suspected or confirmed in the opinion of the trial implementer, or any other high bleeding risk. - Thrombocytopenia: platelet count < 100×10 9 / L - Reduced platelet function: < 60% ADP-induced platelet aggregation - Existing coagulation factor deficiency: not limited, such as fibrinogen <2.5 - 2.8 g / L, etc. Patients with a risk of bleeding at the time of screening, defined as such. 4. Any emergency surgery performed within less than 30 days before screening, such as aortic dissection and / or large congenital heart defect. 5. Scheduled to undergo cardiac surgery with cardiopulmonary bypass (CPB) off or hypothermic circulatory arrest. 6. Scheduled to receive only TAVI or TAVR, or single-vessel, minimally invasive coronary artery bypass (MIDCAB) off-pump surgery, or left ventricular assist device (LVAD) implantation (Note: See Inclusion Criteria 8). 7. Cardiogenic shock or hemodynamic instability within 4 weeks before surgery, requiring inotropic agents, vasopressors, or mechanical devices such as intra-aortic balloon counterpulsation (IABP). 8. Required any of defibrillators, mechanical ventilation, IABP, LVAD, or other forms of mechanical circulatory support (MCS) within 4 weeks before cardiac surgery. 9. Received cardiopulmonary resuscitation (CPR) within 30 days before cardiac surgery. 10. Other conditions requiring recent stent placement within 30 days before cardiac surgery or restart of P2Y12 inhibitor therapy within 48 hours or less after surgery. 11. Cardiopulmonary bypass (CPB) duration <60 minutes. 12. Patients with active bleeding at the end of surgery, according to the evaluation of the surgical team. 13. Use of other investigational drugs at the time of registration, or within 5 times the half-life from registration, or until the expected PD effect returns to baseline, whichever is the longer period, or a longer period if required by regional regulations. 14. History of hypersensitivity to investigational treatment, its excipients, or drugs of a similar chemical class. 15. Known medical history (within 6 months before screening) or currently clinically significant arrhythmia associated with syncope, dyspnea, or hemodynamic instability. 16. Patients who have undergone nephrectomy. 17. Concomitant use of agents known to prolong the QT interval (QT > 500 ms and at the discretion of the study investigator), unless it can be permanently interrupted during the study period. 18. Intake of drugs prohibited by the protocol. 19. History of malignant disease in any organ system, treated or untreated within the past 5 years, regardless of evidence of local recurrence or metastasis (except for localized basal cell carcinoma of the skin or carcinoma in situ of the cervix). 20. Blood donation or loss of > 450 mL of blood or plasma donation or loss of > 200 ml within 4 weeks prior to dosing or for a longer period if required by local regulations. 21. History of organ or cell transplantation requiring active immunosuppressive therapy (e.g., calcineurin inhibitors) that may interfere with renal function. 22. History of ongoing sepsis or a history of sepsis within the past 8 weeks, or having an untreated infection diagnosed prior to the screening visit. Sepsis is defined as the presence of a pathogen confirmed with fever or hypothermia and low perfusion or hypotension. 23. New York Heart Association (NYHA) class IV heart failure as defined by the heart function classification. 24. Left ventricular ejection fraction < 30% by the most recent available echocardiogram. 25. Recent history (within the past 3 years) of autonomic neuropathy and / or a history of recurrence (e.g., recurrent episodes such as syncope, palpitations, etc.). 26. Surgery or medical conditions that can significantly alter drug absorption, distribution, metabolism, or excretion or that can place participants at risk in the event of participating in the study. The study investigator · Inflammatory bowel disease, peptic ulcer, gastrointestinal bleeding including rectal bleeding; · Major gastrointestinal surgery such as gastrectomy, gastroenterostomy, or intestinal resection; · Pancreatic injury or pancreatitis; · Liver disease or liver injury indicated by abnormal liver function tests: ALT (SGPT), AST (SGOT), GGT, alkaline phosphatase, and serum bilirubin are tested; · Evidence of urinary tract obstruction or difficulty urinating at the time of screening This decision should be made taking into account the medical history of any of the participants and / or clinical or experimental evidence. If necessary, laboratory tests can be repeated once (as soon as possible) before randomization to exclude laboratory errors. 27. History of immunodeficiency diseases (evaluated according to regional trials??). Will tuberculosis also be added? 28. (History) of chronic infections with hepatitis B (HBV) or hepatitis C (HCV). Participants are excluded by the HBV core antibody test if the HBV surface antigen (HBsAg) test is positive or it is a standard regional medical treatment. Active hepatitis defined by active AST / ALT??? (from sepsis trials?) 29. Drug abuse or unhealthy alcohol consumption within 12 months before dosing # or evidence of such abuse shown by laboratory assays performed during screening. # Unhealthy alcohol consumption is defined as a history of alcohol misuse / abuse or current alcohol misuse / abuse defined as "more than 5 drinks of alcohol on the same occasion on 5 or more days in the past 30 days". 30. Pregnant or lactating (breastfeeding) women. 31. Women who are potentially pregnant, defined as all women who can become physiologically pregnant unless they are using a highly effective method of contraception during the investigational treatment and until the end of the trial. Highly effective methods of contraception include · Total abstinence (if this is consistent with the participant's preferred and usual lifestyle). Periodic abstinence (e.g., calendar method, ovulation method, symptothermal method, post-ovulation method) and drug withdrawal, which is not an acceptable method of contraception. · Bilateral tubal ligation in women at least 6 weeks before administration of the investigational drug, female sterilization (who has undergone bilateral oophorectomy with or without hysterectomy) or total hysterectomy. In the case of oophorectomy only, only if the female reproductive status has been confirmed by hormonal level evaluation during follow-up. · Male sterilization (for at least 6 months before screening). For female participants in the trial, the vasectomized male partner should be the participant's only partner. · Use of oral contraception (estrogen and progesterone), injectable or implantable hormonal methods, or intrauterine devices (IUDs) or intrauterine systems (IUSs), or other forms of hormonal contraception with comparable effectiveness (failure rate < 1%), such as hormonal contraceptive vaginal rings or transdermal hormonal contraception methods.

[0090] Example 6 A multicenter, randomized, double-blind, placebo-controlled, 4-arm, parallel-group, dose-escalation Phase 2b trial to investigate the safety and efficacy of CD39* in the treatment of patients with sepsis-associated acute kidney injury (SA-AKI) This is a double-blind, placebo-controlled, 4-arm, parallel-group, dose-escalation Phase 2b trial. Approximately 320 participants will be randomized in a 3:1:1:3 ratio to one of three single-dose CD39* doses of 4 mg / kg, 2 mg / kg, 1 mg / kg or placebo.

[0091] Main inclusion criteria · Aged 18 years or older and 85 years or younger. · Admission to the ICU or intermediate intensive care unit / high-dependency unit (HDU). · The following: - Suspected or confirmed infection, and - A rapid increase in the SOFA score of 2 or more (excluding renal function) Based on the criteria defined by The Third International Consensus Definitions for sepsis and septic shock (Sepsis-3). The baseline SOFA score should be assumed to be zero unless it is known that the participant has pre-existing (acute or chronic) organ dysfunction before the onset of infection. · Diagnosis of AKI stage 1 or higher according to the following criteria at the time of randomization: An absolute increase in serum or plasma creatinine of 0.3 mg / dL or more (26.5 μmol / L or more) within 48 hours or presumed to have occurred in the previous 48 hours compared to the reference creatinine before sepsis. · For hospital-acquired AKI, the stable serum creatinine obtained in the hospital before the AKI diagnosis should be used as the reference serum creatinine. · For patients presented from the community, the reference serum creatinine before sepsis should be in the following order of priority: 1. The most recent value within 3 months of admission. If not available: 2. The most recent value during the 3 - 12 months before admission. If not available: 3. The value at the time of admission should be used for estimation.

[0092] Major exclusion criteria · History of chronic kidney disease (CKD) with a pre - admission recorded eGFR < 45 ml / min. · eGFR < 45 mL / min at admission without another reference serum eGFR within the past 12 months · Receiving or having a decision to initiate renal replacement therapy (RRT) within 24 hours of admission. · Diagnosis of sepsis according to the inclusion criteria for a period exceeding 72 hours before ICU admission. · Diagnosis of AKI according to the AKI inclusion criteria for 48 hours after ICU admission. · Unable to administer the investigational drug within 24 hours of the diagnosis of AKI according to the AKI inclusion criteria. · Presence of AKI according to the opinion of the investigator, suggested by clinical signs such as prolonged oliguria or severe renal insufficiency at admission without a history of CKD, for a period exceeding 24 hours before the administration of the investigational drug. · Evidence of recovery from AKI based on the clinical judgment of the investigator before randomization. · History of (proven by biopsy) or suspected acute or sub - acute kidney disease, such as rapidly progressive glomerulonephritis (RPGN) and acute interstitial nephritis (AIN). · Participants who are thrombocytopenic (platelet count < 50,000 microliters) at the screening time point or have a high risk of bleeding according to the opinion of the trial implementer.

[0093] Primary objective: · To evaluate the dose - response relationship of CD39* on renal function measured by creatinine clearance (CrCl) in participants with SA - AKI.

[0094] Secondary objectives: · To evaluate the effect of CD39* compared to placebo in reducing major renal disease adverse events · To evaluate the effect of CD39* compared to placebo on the improvement of renal function · To evaluate the effect of CD39* compared to placebo on the improvement of overall health status · To evaluate the safety and tolerability of CD39* compared to placebo.

[0095] The secondary estimands are defined by the evaluation of the treatment effect of the trial for the following endpoints and summary measures: · MAKE (death, RRT, a decrease in eGFR of 25% or more) at day 90: The summary measure is the odds ratio of participants with MAKE. · Weighted mean of the area under the curve of timed - corrected endogenous creatinine clearance from day 1 to day 14 and from day 1 to day 30: The summary measure is the geometric mean. · Weighted mean of the area under the curve of timed - corrected endogenous serum cystatin C from day 1 to day 14 and from day 1 to day 30: The summary measure is the geometric mean. · Weighted mean of the area under the curve of timed - corrected endogenous creatinine clearance from day 5 to day 14 (AUC5 - 14). The estimated framework is the same as the primary evaluation item. · Any use of RRT during the trial: The summary measure is the odds ratio of participants with RRT. · RRT dependence at day 90: The summary measure is the odds ratio of participants with RRT. ·Days alive during the trial and not including RRT: The summary measure is the mean number of days alive and not including RRT. ·Proportion of participants with a ≥25% decrease in eGFR at day 90: The summary measure is the odds ratio of participants with a ≥25% decrease in eGFR. ·KDIGO AKI stage: The summary measure is the change in status from baseline in the KDIGO AKI stage on day 14. ·Change in SOFA score from baseline to day 30: The summary measure is the mean change in SOFA score from baseline.

[0096] Potential trial participants had a recent diagnosis of sepsis according to the criteria defined by The Third International Consensus Definitions for sepsis and septic shock (Sepsis-3) following the diagnosis of AKI.

[0097]

Table 2

[0098]

Table 3

[0099]

Table 4

[0100]

Table 5

[0101]

Table 6

[0102]

Table 7

[0103]

Table 8

[0104]

Table 9

[0105]

Table 10

[0106]

Table 11

[0107]

Table 12

Claims

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

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

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

4. The recombinant CD39 according to any one of claims 1 to 3, wherein the severity of AKI is reduced by at least one stage as defined by the modified Acute Kidney Injury Network (AKIN) criteria for serum creatinine.

5. The recombinant CD39 according to any one of claims 1 to 4, which is administered at a dose of about 0.1 mg / kg to about 10 mg / kg of the recombinant CD39.

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

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

8. The recombinant CD39 according to any one of claims 1 to 7, which is administered by IV.

9. The recombinant CD39 according to any one of claims 1 to 8, which is administered within several hours after AKI is first diagnosed in the subject.

10. The recombinant CD39 according to any one of claims 1 to 9, which is administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours) after AKI is first diagnosed in the subject.

11. The recombinant CD39 according to any one of claims 1 to 10, wherein the AKI is sepsis-associated acute kidney injury (SA-AKI).

12. The recombinant CD39 according to any one of claims 1 to 11, wherein the AKI is cardiac surgery-associated AKI (CSA-AKI).

13. The recombinant CD39 according to any one of claims 1 to 12, which is used in a method for preventing or treating one or more symptoms associated with AKI.

14. The recombinant CD39 according to any one of claims 1 to 13, which has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

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

16. The recombinant CD39 of claim 15, for use as a medicament, administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

17. The recombinant CD39 of claim 16, having the amino acid sequence of SEQ ID NO:

21.

18. The recombinant CD39 of any one of claims 1 to 17, administered to the subject as a monotherapy.

19. The recombinant CD39 of any one of claims 1 to 18, co-administered with an additional therapeutic agent.

20. 20. The recombinant CD39 of claim 19, co-administered with an additional therapeutic agent selected from a steroid, a metalloproteinase inhibitor, a serine protease inhibitor, a local anesthetic emulsion, a diffusion factor inhibitor, an antiemetic, or an antibiotic.

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