Treatment of IGA nephropathy with endothelin receptor antagonist and APRIL-binding antibody

Abstract

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

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of the filing date of U.S. Provisional Patent Application No. 63 / 420,305, filed October 28, 2022, and U.S. Provisional Patent Application No. 63 / 420,504, filed October 28, 2022, the entire contents of each of which are incorporated herein by reference.

[0002] Sequence Listing This document contains a Sequence Listing in electronic format that was submitted to the U.S. Patent and Trademark Office via its electronic filing system. The XML file incorporated by reference herein is entitled "sequence.XML", was created on October 27, 2022, and is 50.2 bytes in size.

[0003] The present disclosure relates to the use of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an isolated antibody, including a fragment thereof, that binds to human APRIL, for the treatment of IgA nephropathy. [Background technology]

[0004] IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Abnormal glycosylation of IgA1 leads to increased serum levels of galactose-deficient IgA1 (Gd-IgA1), which is recognized by glycan-specific IgA and IgG autoantibodies. Immune complex aggregates form in situ and / or are deposited in the glomerular mesangium. This promotes mesangial cell proliferation, increased synthesis of extracellular matrix proteins, cytokines, and chemokines, and immune cell infiltration into surrounding tissues. Therefore, disease progression involves (1) the production of Gd-IgA1 and (2) its recognition by anti-glycan autoantibodies, which leads to (3) immune complex formation in the kidney and (4) mesangial cell activation. See, for example, Penfold et al., Int. J. Nephrol. and Renovascular Dis. 11, pp. 137-148 (2017).

[0005] Unlike other progressive kidney diseases, such as diabetic nephropathy, IgAN primarily affects healthy subjects in their 20s and 30s. Patients typically present with a variety of symptoms, including microhematuria or macrohematuria and increased urinary protein excretion. Patients may also develop hypertension as a result of persistent renal damage. Current treatment approaches provide only symptomatic treatment, including the administration of maximum tolerated doses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or immunosuppressants, but the adverse effects far outweigh the benefits. Ultimately, 30–40% of patients develop end-stage renal disease (ESRD) within 20–30 years of IgAN diagnosis. During this time, patients experience a number of symptoms that significantly reduce their quality of life, in addition to declining renal function. Patients with IgAN often exhibit significantly increased expression of endothelin-1 (ET-1) and ET-RA in the kidneys. Increased endothelin expression is positively correlated with proteinuria, one of the hallmark symptoms of IgAN.

[0006] APRIL is expressed as a type II transmembrane protein; however, unlike most other TNF family members, it is primarily processed as a secreted protein and cleaved in the Golgi apparatus, where it is cleaved by furin convertase to release a soluble, active form (Lopez-Fraga et al., 2001, EMBO Rep 2:945-51). APRIL assembles as a noncovalent homotrimer with similar structural homology to many other TNF family ligands in terms of protein fold (Wallweber et al., 2004, Mol Biol 343:283-90). APRIL binds to two TNF receptors: B-cell maturation antigen (BCMA) and transmembrane activator and calcium regulator and cyclophilin ligand interactor (TACI) (reviewed in Kimberley et al., 2009, J Cell Physiol. 218(1):1-8). In addition, APRIL has recently been shown to bind to heparan sulfate proteoglycans (HSPGs) (Hendriks et al., 2005, Cell Death Differ 12, 637-48). APRIL has been shown to play a role in B cell signaling, driving both proliferation and survival of human and mouse B cells in vitro (reviewed in Kimberley et al., 2009, J Cell Physiol. 218(1):1-8).

[0007] APRIL is primarily expressed by immune cell subsets, such as monocytes, macrophages, dendritic cells, neutrophils, B cells, and T cells, many of which also express BAFF. Furthermore, APRIL can be expressed by non-immune cells, such as osteoclasts, epithelial cells, and various tumor tissues (reviewed in Kimberley et al., 2009, J Cell Physiol. 218(1):1-8). Indeed, APRIL was initially identified based on its expression in cancer cells (Hahne et al., 1998, J Exp Med 188, 1185-90). High-level expression of APRIL mRNA was found in a range of tumor cell lines and human primary tumors, such as colon and lymphoid carcinomas. APRIL serum levels have been found to be increased in patients with IgA nephropathy (McCarthy et al., 2011, J. Clin. Invest. 121(10):3991-4002).

[0008] Serum Gd-IgA1 levels have been reported to be significantly higher in IgAN patients compared with diseased and healthy controls. In IgAN patients, serum Gd-IgA1 levels were significantly correlated with estimated glomerular filtration rate, serum IgA levels, and tubular atrophy / interstitial fibrosis. CKD progression was more frequent in IgAN patients with high serum Gd-IgA1 levels than in patients with low serum Gd-IgA1 levels. A Cox proportional hazards model showed that high GdIgA1 levels were an independent risk factor for CKD progression after adjusting for several confounding factors. Kim et al., J. Clin. Med. 2020 Nov 4;9(11):3549. doi:10.3390 / jcm9113549.

[0009] The established standard of care for most patients with IgA nephropathy involves providing symptomatic measures, including blockade of the renin-angiotensin-aldosterone system. Many patients are also provided with corticosteroid therapy or other immunosuppressants, despite clear evidence that the benefits of these therapies outweigh the risks.

[0010] To improve the care of patients with IgAN, at least two antibodies against APRIL, BION-1301 and sibeprenlimab (VIS649), are currently in clinical trials for the treatment of IgAN. See, e.g., U.S. ClinicalTrials.gov identifiers NCT05508204, NCT03945318, NCT03719443, NCT05248659, and NCT05248646. Similarly, the endothelin receptor antagonists atrasentan and sparsentan are in clinical trials for the treatment of IgAN. See, e.g., U.S. ClinicalTrials.gov identifiers NCT04573478, NCT05834738, NCT04573920, and NCT04663204. Furthermore, a subanalysis of the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial provided early evidence that the SGLT-2 inhibitor dapagliflozin may be a safe and effective addition to current standard treatment in IgA nephropathy. Wheeler et al., Kidney International (2021) 100: 215-224. Summary of the Invention

[0011] Atrasentan is a selective endothelin A (ETA) receptor antagonist (ETA Ki approximately 34 pM; ETB Ki approximately 63 nM, ETA selectivity approximately 1800-fold). See, e.g., Wu-Wong et al., Clin. Sci. (London), 103(48), pp. 107s-111s (2002). Selective ETA receptor antagonists block ETA function while minimizing the effect on the ETB receptor, while still allowing ET-1 clearance and providing beneficial renal effects, including vasodilation and reduced inflammation. See, e.g., Jandeleith-Dahm and Watson, Curr. Opin. Nephrol. Hypertens., 21(1), pp. 66-71 (2012). See also Nakamura, et al., Nephron, Vol. 72, pp. 454-460 (1996). ETA receptor antagonists increase renal sodium and water retention, which is typically clinically manageable. See, e.g., Saleh, et al., J. Pharm. Exp. Ther., 338(1), pp. 263-270 (2011). Atrasentan has been shown to be effective in patients with diabetic kidney disease (DKD), significantly reducing the risk of renal events, defined as a doubling of serum creatinine or end-stage renal disease. See, e.g., Heerspink, et al., The Lancet, 393, pp. 1937-1947 (2019).

[0012] Sparsentan is a dual-acting angiotensin II subtype 1 receptor blocker ("ARB") and ETA receptor antagonist. Trachtman, et al., J. Am. Soc. Nephrol. Vol. 29, No. 11, pp. 2745-2754 (2018).

[0013] IgA nephropathy is considered a primary glomerular disease in which focal or intrinsic renal pathology is present. The peak incidence of IgA nephropathy occurs in young individuals in their teens or twenties, and unlike diabetic kidney disease (DKD), it is an autoimmune-based disease. IgA nephropathy results from the deposition of pathogenic IgA / immune complexes in the glomerular mesangium. See, for example, Lai, et al., Nature Reviews Disease Primers, 2, pp. 16001, 2016. Definitive diagnosis requires renal biopsy and evidence of mesangial IgA deposition by immunofluorescence microscopy. Recent advances in understanding the initiating events that trigger IgA nephropathy have revealed that an abnormal mucosal immune response stimulates the production of galactose-deficient IgA1, which is recognized as an autoantigen by circulating antiglycan autoantibodies. Immune recognition leads to the formation of nephrogenic immune complexes that deposit in the kidney and activate mesangial cells. Activated mesangial cells proliferate and produce excessive amounts of extracellular matrix components, cytokines, and chemokines. See, e.g., Suzuki, et al., J. Am. Soc. Nephrol., Vol. 22, pp. 1795-1803 (2011). Up to 40% of patients with biopsy-proven IgA nephropathy progress to end-stage renal disease at some point during long-term follow-up. As described in more detail herein, atrasentan can be administered at effective doses with acceptable toxicity and with suitable selectivity to minimize undesirable side effects, while treating the underlying IgAN disease and improving the subject's quality of life. In some embodiments, a method of inhibiting mesangial cell activation in a subject with IgA nephropathy is provided, comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof.

[0014] The majority of subjects with IgAN present with either single or episodic gross hematuria or for the first time after the detection of microscopic hematuria and / or proteinuria during routine urinalysis. In some cases, subjects present with acute kidney injury, such as crescentic IgAN or gross hematuria resulting in tubular obstruction. A definitive diagnosis of IgAN is typically established by renal biopsy with immunofluorescence and / or immunoperoxidase testing for IgA deposits. Spherical deposits of IgA (sometimes accompanied by C3 and IgG), prominent within the mesangium and less prominent along the glomerular capillary walls, are characteristic of IgAN. Specific histopathological features correlated with long-term outcomes include mesangial proliferation, endocapillary proliferation, segmental scarring, and tubular atrophy.

[0015] In some embodiments, a method for treating IgA nephropathy is provided, comprising administering to a subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof.

[0016] In some embodiments, a method is provided for inhibiting mesangial cell activation in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof.

[0017] In some embodiments, inhibiting mesangial cell activation comprises reducing the activity of one or more biomarkers indicative of mesangial cell inflammation and / or mesangial cell proliferation.

[0018] In some embodiments, reducing mesangial cell inflammation comprises reducing the expression and / or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation.

[0019] In some embodiments, inhibiting mesangial cell activation comprises reducing a pro-fibrotic response in mesangial cells.

[0020] In some embodiments, mesangial activation is induced by IgA immune complexes.

[0021] In some embodiments, mesangial activation is associated with the presence of IgA immune complexes.

[0022] In some embodiments, a method is provided for reducing nephritis and / or fibrosis in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof.

[0023] In some embodiments, a method for reducing the incidence of hematuria in a subject with IgA nephropathy is provided, comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0024] In some embodiments, a method for stabilizing eGFR in a subject with IgA nephropathy is provided, comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0025] In some embodiments, a method is provided for reducing the number of IgA nephropathy-associated disease flares in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof.

[0026] In some embodiments, provided is a method for delaying the onset of end-stage renal disease (ESRD) in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0027] In some embodiments, a method for reducing proteinuria in a subject with IgA nephropathy is provided, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0028] In some embodiments, a method for reducing fatigue in a subject with IgA nephropathy is provided, comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0029] In some embodiments, determining that the subject has IgA immune complex deposits in the kidney occurs before the administering step. In some embodiments, determining that the subject has elevated levels of mesangial activation occurs before the administering step. In some embodiments, determining that the subject has elevated levels of IgA immune complexes in the kidney occurs before the administering step.

[0030] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is selected from the group consisting of tezosentan, spysentan, bosentan, sparsentan, macitentan, ambrisentan, sitaxsentan, atriopeptin, atrasentan, and pharmaceutically acceptable salts of any of the foregoing, and combinations thereof.

[0031] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is sparsentan, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0032] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is atrasentan, or a pharmaceutically acceptable salt thereof. In some embodiments, atrasentan is administered as a pharmaceutically acceptable salt. In some embodiments, a pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride or atrasentan mandelate. In some embodiments, a pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride. In some embodiments, a pharmaceutically acceptable salt of atrasentan is atrasentan mandelate. In some embodiments, atrasentan is administered as the free base.

[0033] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, a heavy chain complementarity determining region 1 (HC CDR1) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO: 1; a heavy chain complementarity determining region 2 (HC CDR2) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO: 2; a heavy chain complementarity determining region 3 (HC CDR3) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO: 3; a light chain complementarity determining region 1 (LC CDR1) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO: 4; a light chain complementarity determining region 2 (LC CDR2) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:5; and It comprises a light chain complementarity determining region 3 (LC CDR3) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:6.

[0034] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, a heavy chain complementarity determining region 1 (HC CDR1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 1; a heavy chain complementarity determining region 2 (HC CDR2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 2; a heavy chain complementarity determining region 3 (HC CDR3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 3; a light chain complementarity determining region 1 (LC CDR1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 4; a light chain complementarity determining region 2 (LC CDR2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:5; and It comprises a light chain complementarity determining region 3 (LC CDR3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:6.

[0035] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, Heavy chain complementarity determining region 1 (HC CDR1) comprising the amino acid sequence of SEQ ID NO: 1; Heavy chain complementarity determining region 2 (HC CDR2) comprising the amino acid sequence of SEQ ID NO: 2; Heavy chain complementarity determining region 3 (HC CDR3) comprising the amino acid sequence of SEQ ID NO: 3; a light chain complementarity determining region 1 (LC CDR1) comprising the amino acid sequence of SEQ ID NO: 4; a light chain complementarity determining region 2 (LC CDR2) comprising the amino acid sequence of SEQ ID NO: 5; and It contains a light chain complementarity determining region 3 (LC CDR3) comprising the amino acid sequence of SEQ ID NO:6.

[0036] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24.

[0037] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24.

[0038] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24.

[0039] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:26.

[0040] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:26.

[0041] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising the amino acid sequence of SEQ ID NO:26.

[0042] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:28.

[0043] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:28.

[0044] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID NO:28.

[0045] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:30.

[0046] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:30.

[0047] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising the amino acid sequence of SEQ ID NO:30.

[0048] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretory leader comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:32.

[0049] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretory leader comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:32.

[0050] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretory leader comprising the amino acid sequence of SEQ ID NO:32.

[0051] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain secretory leader comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO:34.

[0052] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain secretory leader comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:34.

[0053] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain secretory leader comprising the amino acid sequence of SEQ ID NO:34.

[0054] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising one of SEQ ID NOs: 7, 9, 11, 13, 15, 17, 19, 21, or 23.

[0055] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID NO:25.

[0056] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID NO:27.

[0057] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID NO:29.

[0058] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID NO:31.

[0059] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID NO:33.

[0060] In some embodiments, the methods comprise administering to a subject an amount of atrasentan or a pharmaceutically acceptable salt thereof equivalent to about 0.20 mg to about 1.50 mg of atrasentan free base. In some embodiments, the methods comprise administering to a subject an amount of atrasentan hydrochloride equivalent to about 0.20 mg to about 1.50 mg of atrasentan free base.

[0061] In some embodiments, the methods comprise administering to a subject an amount of atrasentan or a pharmaceutically acceptable salt thereof equivalent to about 0.25 mg to about 1.25 mg of atrasentan free base. In some embodiments, the methods comprise administering to a subject an amount of atrasentan hydrochloride equivalent to about 0.25 mg to about 1.25 mg of atrasentan free base.

[0062] In some embodiments, the method comprises administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, in an amount equivalent to about 0.40 mg to about 0.85 mg of atrasentan free base. In some embodiments, the method comprises administering to the subject an amount of atrasentan hydrochloride equivalent to about 0.40 mg to about 0.85 mg of atrasentan free base.

[0063] In some embodiments, the methods comprise administering to a subject an amount of atrasentan or a pharmaceutically acceptable salt thereof equivalent to about 0.50 mg of atrasentan free base. In some embodiments, the methods comprise administering to a subject an amount of atrasentan hydrochloride equivalent to about 0.50 mg of atrasentan free base.

[0064] In some embodiments, the methods comprise administering to a subject an amount of atrasentan or a pharmaceutically acceptable salt thereof equivalent to about 0.75 mg of atrasentan free base. In some embodiments, the methods comprise administering to a subject an amount of atrasentan hydrochloride equivalent to about 0.75 mg of atrasentan free base.

[0065] In some embodiments, the methods comprise administering to a subject an amount of sparsentan or a pharmaceutically acceptable salt thereof equivalent to about 200 mg of sparsentan free base.

[0066] In some embodiments, the methods comprise administering to a subject an amount of sparsentan or a pharmaceutically acceptable salt thereof equivalent to about 400 mg of sparsentan free base.

[0067] In some embodiments, the methods comprise administering to a subject an amount of sparsentan or a pharmaceutically acceptable salt thereof equivalent to about 600 mg of sparsentan free base.

[0068] In some embodiments, the methods comprise administering to a subject an amount of sparsentan or a pharmaceutically acceptable salt thereof equivalent to about 800 mg of sparsentan free base.

[0069] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered orally, buccally, or parenterally, e.g., oral route dosage forms can be tablets, capsules, powders, pills, granules, suspensions, solutions, and solution preconcentrates, emulsions, and emulsion preconcentrates, and parenteral route dosage forms can be intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal, or transmucosal administration.

[0070] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered once daily.

[0071] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is administered by a parenteral route, such as intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal transmission, or transmucosal administration.

[0072] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is formulated into a solution, lyophilized product, or powder for injection.

[0073] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is administered for 2, 3, 4, 5, 6, 7, 8, 9, or 10 days, or once every 1, 2, or 3 weeks; alternatively, the APRIL binding antibody, or antigen-binding fragment thereof, may be administered once daily for 5 consecutive days per week, followed by a 2-day interval.

[0074] In some embodiments, about 0.05 mg / kg to about 8 mg / kg of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

[0075] In some embodiments, about 0.05 mg / kg to about 4 mg / kg of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

[0076] In some embodiments, about 2 mg / kg to about 6 mg / kg of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

[0077] In some embodiments, about 4 mg / kg to about 8 mg / kg of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

[0078] In some embodiments, about 0.05 mg / kg, about 0.1 mg / kg, about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, about 5 mg / kg, about 6 mg / kg, about 7 mg / kg, or about 8 mg / kg of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

[0079] In some embodiments, the methods comprise repeating the administration of an APRIL binding antibody, or antigen-binding fragment thereof, on at least a once-weekly (QW) schedule for at least two administration cycles.

[0080] In some embodiments, the methods involve repeating the administration of an APRIL binding antibody, or antigen-binding fragment thereof, on a schedule of at least once every two weeks (Q2W) for at least two administration cycles.

[0081] In some embodiments, the method comprises repeating administration of an APRIL binding antibody, or antigen-binding fragment thereof, on a schedule of at least once every four weeks (Q4W) or once a month (QMT) for at least two administration cycles.

[0082] In some embodiments, a total dose of between about 10 mg and about 1350 mg of APRIL binding antibody, or antigen-binding fragment thereof, is administered per dosing event.

[0083] In some embodiments, about 2 mL of a formulation having an APRIL binding antibody, or antigen-binding fragment thereof, concentration of about 150 mg / mL is delivered per administration, and each administration event comprises one or more of the above administrations.

[0084] In some embodiments, about 4 mL of a formulation having an APRIL binding antibody, or antigen-binding fragment thereof, concentration of about 150 mg / mL is delivered per administration, and each administration event comprises one or more of the above administrations.

[0085] In some embodiments, the formulation of an APRIL binding antibody, or antigen-binding fragment thereof, is administered subcutaneously to the individual at a site in the thigh, abdomen, or upper arm.

[0086] In some embodiments, the formulation of an APRIL binding antibody, or antigen-binding fragment thereof, is administered intravenously.

[0087] In some embodiments, 15 mL of a 20 mg / mL concentration formulation is added to 235 mL of 0.9% saline to provide an intravenous dose of 1.2 mg / mL concentration.

[0088] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is administered by a loading / maintenance administration protocol. In some embodiments, the loading component of the loading / maintenance administration protocol comprises one or more administrations of the APRIL binding antibody, or antigen-binding fragment thereof, at a concentration that is higher than the concentration of the APRIL binding antibody, or antigen-binding fragment thereof, in the maintenance component of the loading / maintenance administration protocol. In some embodiments, the loading component of the loading / maintenance administration protocol comprises one or more administrations of the APRIL binding antibody, or antigen-binding fragment thereof, at a higher frequency than the frequency of administration of the APRIL binding antibody, or antigen-binding fragment thereof, in the maintenance component of the loading / maintenance administration protocol.

[0089] In some embodiments, the subject has been determined to have controlled serum glucose levels.

[0090] In some embodiments, the subject is concurrently receiving an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin II receptor blocker (ARB), or a combination thereof.

[0091] In some embodiments, the ACE inhibitor is selected from the group consisting of quinapril, fosinopril, perindopril, captopril, enalapril, enalaprilat, ramipril, cilazapril, delapril, fosenopril, zofenopril, indolapril, benazepril, lisinopril, spirapril, trandolapril, perindep, pentopril, moexipril, rescinnamine, and pivopril.

[0092] In some embodiments, the ACE inhibitor is selected from the group consisting of quinapril, fosinopril, captopril, enalapril, and lisinopril.

[0093] In some embodiments, the ARB is selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657.

[0094] In some embodiments, the ARB is selected from the group consisting of candesartan, losartan, olmesartan, and valsartan.

[0095] In some embodiments, the method further comprises administering a therapeutically effective amount of an SGLT-2 inhibitor.

[0096] In some embodiments, the SGLT-2 inhibitor is dapagliflozin, canagliflozin, ipragliflozin, empagliflozin, bexagliflozin, licogliflozin, janagliflozin (XZP-5695), tofogliflozin, ertugliflozin, henagliflozin (SHR-3824), enavogliflozin (DWP-16001), TA-1887 (3-(4-cyclopropylbenzyl)-4-fluoro-1-(β-D-glucopyranosyl)-1H-indole), indole-N-glycosyl and T-1095 (((2R,3S,4S,5R,6S)-6-(2-(3-(benzofuran-5-yl)propanoyl)-3-hydroxy-5-methylphenoxy)-3,4,5-trihydroxytetrahydro-2H-pyran-2-yl)etabonate).

[0097] In some embodiments, the SGLT-2 inhibitor is selected from the group consisting of bexagliflozin, canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin, luseogliflozin, remogliflozin, cetylflozin, licofliglozin, sotagliflozin, and tofogliflozin.

[0098] In some embodiments, the SGLT-2 inhibitor is canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin.

[0099] In some embodiments, administering the combination comprises administering an APRIL binding antibody, or antigen-binding fragment thereof, and one or both of an endothelin receptor antagonist and an SGLT-2 inhibitor simultaneously, separately, or sequentially.

[0100] In some embodiments, administering the combination comprises administering the APRIL binding antibody, or antigen-binding fragment thereof, and the endothelin receptor antagonist by different routes of administration.

[0101] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is administered intravenously or subcutaneously and the endothelin receptor antagonist is administered orally.

[0102] In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, and the endothelin receptor antagonist are administered on different dosing schedules.

[0103] In some embodiments, the subject is administered an SGLT-2 inhibitor and one or more ACE inhibitors and / or one or more ARBs.

[0104] In some embodiments, the subject is administered an SGLT-2 inhibitor and one or more ACE inhibitors.

[0105] In some embodiments, the subject is administered an SGLT-2 inhibitor and an ACE inhibitor.

[0106] In some embodiments, the subject is administered an SGLT-2 inhibitor and one or more ARBs.

[0107] In some embodiments, the subject is administered an SGLT-2 inhibitor and an ARB.

[0108] In some embodiments, the SGLT-2 inhibitor is administered orally, buccally, or parenterally. In some embodiments, the oral dosage form is selected from the group consisting of tablets, capsules, powders, pills, granules, suspensions, solutions, and solution preconcentrates, emulsions, and emulsion preconcentrates. In some embodiments, the parenteral route is selected from the group consisting of intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal, and transmucosal administration.

[0109] In some embodiments, the subject excretes an average of about 0.5 grams or more of protein in the urine per day prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof.

[0110] In some embodiments, the subject excretes an average of about 1 gram or more of protein in the urine per day prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof.

[0111] In some embodiments, the subject has an average blood flow rate of at least about 30 mL / min / 1.73 m prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof. 2 have a mean eGFR of

[0112] In some embodiments, a kit is provided, comprising an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, wherein the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, may be in the same and / or separate dosage forms. In some embodiments, the kit may further comprise an SGLT-2 inhibitor.

[0113] In some embodiments, a kit is provided, the kit comprising an SGLT-2 inhibitor and an APRIL binding antibody, or antigen-binding fragment thereof, wherein the SGLT-2 inhibitor and the APRIL binding antibody, or antigen-binding fragment thereof, may be in the same and / or separate dosage forms.

[0114] All publications, patents, patent applications, and information available on the Internet and referred to in this specification are incorporated herein by reference to the same extent as if each individual publication, patent, patent application, or item of information was specifically and individually indicated to be incorporated by reference. To the extent that the publications, patents, patent applications, and items of information incorporated by reference conflict with the present disclosure contained herein, the present specification is intended to supersede and / or supersede such conflicting material.

[0115] Various embodiments of features of the present disclosure are described herein. However, it should be understood that these embodiments are provided by way of example only, and that numerous variations, changes, and substitutions may occur to those skilled in the art without departing from the scope of the present disclosure. It should also be understood that various alternatives to the specific embodiments described herein are within the scope of the present disclosure. [Brief explanation of the drawings]

[0116] [Figure 1] 1 shows the study schema for a Phase 3, randomized, double-blind, placebo-controlled study of BION-1301 in adults with IgA nephropathy. DETAILED DESCRIPTION OF THE INVENTION

[0117] A.Definition In order that this disclosure may be more readily understood, certain terms are first defined. As used in this application, unless otherwise expressly provided herein, each of the following terms shall have the meaning set forth below. Additional definitions are set forth throughout this application.

[0118] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this disclosure pertains. For example, Concise Dictionary of Biomedicine and Molecular Biology, Juo, Pei-Show, 2nd ed., 2002, CRC Press; The Dictionary of Cell and Molecular Biology, 3rd ed., 1999, Academic Press; and the Oxford Dictionary of Biochemistry and Molecular Biology, Revised, 2000, Oxford University Press provide those skilled in the art with a general dictionary of many of the terms used in this disclosure. For purposes of this disclosure, the following terms are defined:

[0119] Units, prefixes, and symbols are denoted in the accepted format of the Systeme International de Unites (SI). Numerical ranges are inclusive of the numbers defining the range. The headings provided herein are not intended to limit the various aspects of the disclosure, which can be had by reference to the specification in its entirety. Accordingly, the terms defined immediately below are more fully defined by reference to the specification in its entirety.

[0120] The term "about" when referring to a number or range of values ​​means that the number or range of values ​​being referred to is an approximation, e.g., within experimental variation and / or statistical experimental error, and thus the number or range of values ​​may vary by up to ±10% of the stated number or range of values.

[0121] "Treatment" or "therapy" of a subject refers to any type of intervention or process performed on a subject, or administration of an active agent to a subject, with the intent of reversing, alleviating, ameliorating, inhibiting, or slowing the onset, progression, occurrence, severity, or recurrence of symptoms, complications, conditions, or biochemical manifestations associated with a disease.

[0122] A "subject" includes any human or non-human animal. The term "non-human animal" includes, but is not limited to, vertebrates such as non-human primates, sheep, dogs, and rodents such as mice, rats, and guinea pigs. In some embodiments, the subject is a human. The terms "subject" and "patient" and "individual" are used interchangeably herein.

[0123] The phrase "effective amount" or "therapeutically effective amount" refers to an amount of a compound sufficient, when administered to a subject in need of such treatment, to (i) treat the specified disease or disorder, (ii) attenuate, ameliorate, or eliminate one or more symptoms of a particular disease, condition, or disorder, or (iii) delay the onset of one or more symptoms of a particular disease, condition, or disorder described herein. When used in the context of treatment with two or more therapeutic agents, each agent may be administered in an independently therapeutically effective amount (e.g., an amount that is therapeutically effective as a monotherapy), or the one or more therapeutic agents may together amount to a therapeutically effective amount to treat the specified disease or disorder (e.g., a therapeutically effective amount of a combination therapy). In other words, the amount of each component in a therapeutically effective amount of a combination therapy may be administered in a less than therapeutically effective amount (in combination) independently when administered as a monotherapy. An effective amount of a therapeutic agent typically reduces symptoms by at least 10%, usually at least 20%, preferably at least about 30%, more preferably at least 40%, and most preferably at least 50%.

[0124] The terms "synergistic effect" or "synergistic" are used herein to mean that the combined effect of two therapeutic agents of a combination therapy described herein is greater than the sum of the effects of each agent when administered alone (i.e., monotherapy).

[0125] Determining the synergistic interaction between two combination partners, the optimal range for effect, and the absolute dose range of each component for effect can be clearly measured by administering the combination partners over different w / w (weight per weight) ratio ranges and doses to a subject in need of treatment. However, observation of synergistic effects in in vitro or in vivo models can predict effects in humans and other species. As described herein, in vitro and in vivo models exist for measuring synergistic effects, and the results of such studies can also be used to predict effective dose and plasma concentration ratio ranges, as well as absolute doses and plasma concentrations, required in humans and other species by applying pharmacokinetic / pharmacodynamic methods. Exemplary synergistic effects include, but are not limited to, enhanced therapeutic efficacy, reduced dosage at equivalent or increased efficacy levels, reduced or delayed development of drug resistance, and simultaneous enhanced or equivalent therapeutic effects (e.g., the same therapeutic effect as at least one of the therapeutic agents), and reduced undesirable drug effects (e.g., side effects and adverse events) of at least one of the therapeutic agents.

[0126] As used herein, "inhibiting" includes postponing the onset of symptoms associated with the disease and / or reducing the severity of symptoms that will or are expected to develop due to the disease. These terms further include ameliorating existing symptoms, preventing further symptoms, and ameliorating or preventing the underlying causes of such symptoms. Thus, these terms indicate that a beneficial result has been achieved in a vertebrate subject having a disease.

[0127] In some embodiments, an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, exhibits a synergistic effect when administered with an APRIL binding antibody, or an antigen-binding fragment thereof, as described herein. In some embodiments, an APRIL binding antibody, or an antigen-binding fragment thereof, exhibits a synergistic effect when administered with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, as described herein.

[0128] As used herein, the term "endothelin receptor antagonist" refers to a compound that inhibits or blocks the binding of endothelin to an endothelin receptor. Endothelin (ET) is a highly potent vasoconstrictor peptide synthesized and released by vascular endothelium. Endothelin exists in three isoforms, ET-1, ET-2, and ET-3, of which only ET-1 and ET-3 have been found to be expressed in mammalian systems. (Unless otherwise specified, "endothelin," as used herein, shall refer to any or all of the endothelin isoforms.) There are at least two major known endothelin receptors, ET and ET, both of which are G protein-coupled receptors that, upon activation, result in an increase in intracellular free calcium (Davenport (2002) Pharmacol. Rev. 54(2):219-26). Selective ETA receptor antagonists include sitaxsentan (CAS No. 184036-34-8, also described in Barst et al. (2004) American J. Resp. Crit. Care Med. 169(4):441-7); ambrisentan (CAS No. 177036-94-1, also described in U.S. Pat. Nos. 5,703,017, 5,932,730, and 7,109,205); atrasentan (CAS No. 173937-91-2, also disclosed in U.S. Pat. No. 5,767,144); BQ-123 (CAS No. 136553-81-6), and zibotentan (CAS No. 186497-07-4). Dual antagonists of ETA and ETB include bosentan (CAS No. 147536-97-8, also described in Bien et al. (2007) Cancer Res. 67(21):10428-35), macitentan (CAS No. 441798-33-0), and tezosentan (CAS No. 180384-57-0).

[0129] Atrasentan is a selective endothelin A (ETA) receptor antagonist (ETA Ki approximately 34 pM; ETB Ki approximately 63 nM, ETA selectivity approximately 1800-fold). See, e.g., Wu-Wong et al., Clin. Sci. (London), 103(48), pp. 107s-111s (2002). Selective ETA receptor antagonists block ETA function while minimizing the effect on the ETB receptor, while still allowing ET-1 clearance and providing beneficial renal effects, including vasodilation and reduced inflammation. See, e.g., Jandeleith-Dahm and Watson, Curr. Opin. Nephrol. Hypertens., 21(1), pp. 66-71 (2012); see also Nakamura, et al., Nephron, Vol. 72, pp. 454-460 (1996). ETA receptor antagonists increase sodium and water retention by the kidney, which is typically clinically manageable. See, e.g., Saleh, et al., J. Pharm. Exp. Then, 338(1), pp. 263-270 (2011). Atrasentan has been shown to be effective in patients with diabetic kidney disease (DKD), significantly reducing the risk of renal events defined as a doubling of serum creatinine or end-stage renal disease. See, e.g., Heerspink, et al., The Lancet, 393, pp. 1937-1947 (2019).

[0130] Exemplary endothelin receptor antagonist formulations for use in the treatment of IgAN are described in PCT / US2020 / 065311, which is incorporated by reference in its entirety.

[0131] The phrase "pharmaceutically acceptable" indicates that a substance or composition must be chemically and / or toxicologically compatible with the other ingredients that make up the formulation and / or with the mammal being treated therewith.

[0132] As used herein, the term "pharmaceutically acceptable carrier" refers to a substance that aids in the administration of an active agent to a cell, organism, or subject. A "pharmaceutically acceptable carrier" refers to a carrier or excipient that can be included in the compositions of the present disclosure and that does not cause significant adverse toxicological effects to the subject. Non-limiting examples of pharmaceutically acceptable carriers include water, NaCl, saline solution, lactated Ringer's solution, normal sucrose, normal glucose, binders, fillers, disintegrants, lubricants, coatings, sweeteners, flavorings and coloring agents, liposomes, dispersion media, microcapsules, cationic lipid carriers, isotonic and absorption delaying agents, and the like. Carriers can also be substances that provide stability, sterility, and isotonicity to the formulation (e.g., antimicrobial preservatives, antioxidants, chelating agents, and buffers), prevent the action of microorganisms (e.g., antibacterial and antifungal agents, e.g., parabens, chlorobutanol, phenol, sorbic acid, and the like), or provide edible flavors to the formulation. In some cases, the carrier is an agent that facilitates delivery of the small molecule drug or antibody to the target cell or tissue. Those of skill in the art will recognize that other pharmaceutical carriers are useful in the present disclosure.

[0133] As used herein, the term "expression" refers to the level of protein or mRNA in mammalian cells.

[0134] As used herein, the term "activity" refers to one or more activities of a protein, such as binding or enzymatic activity (e.g., one or more of phosphorylation, dephosphorylation, nuclear import, transcriptional activation, transcriptional repression, and / or binding activity to a substrate or binding partner).

[0135] As used herein, the term "IL-6 signaling" refers to the expression and / or activity of one or more proteins in a signaling pathway that begins with IL-6 receptor activation and ends with gene expression. Non-limiting examples of proteins in the signaling pathway that begins with IL-6 receptor activation and ends with gene expression include IL-6 receptor, JAK, STAT3, PI3K, Akt / PKB, IKKs, IkBs, NF-kB, MAPK, Ras, Raf, MEK, and ERK.

[0136] As used herein, the term "NF-kB signaling" refers to the expression and / or activity of one or more of IKKα, IKKβ, IkB, and NF-kB, and / or one or more genes upregulated by NF-kB (e.g., one or more of TNF-α, IL-1, CAM, COX-2, and iNOS).

[0137] As used herein, the term "PDGF signaling" refers to the expression and / or activity of one or more of the PDGF receptor, PKC, PI3K, Src, Ras, ERK1 / 2, Rho, Rac, Akt, mTOR, NAPDH oxidase, MAPK, and cPLA2.

[0138] As used herein, the term "SGLT-2 inhibitor" refers to a compound that inhibits sodium glucose cotransporter 2 (SGLT-2). SGLT-2 inhibitors disrupt glucose reabsorption by the kidney, thus exerting a glucose-lowering effect. SGLT-2 inhibitors have been shown to treat type 2 diabetes and improve cardiovascular outcomes by enhancing glycosuria independently of insulin. See Wright, 2001, Am. J. Physiol. Renal Physiol. 280:F10; and Scheen, 2018, Circ. Res. 122:1439. In some embodiments, the term "SGLT-2 inhibitor" refers to a compound whose primary effect is the inhibition of SGLT-2, but is not limited to compounds that only inhibit SGLT-2, and thus includes compounds that have other activities in addition to SGLT-2 inhibition (e.g., SGLT-1 inhibition).

[0139] In some embodiments, the SGLT-2 inhibitor includes compounds from the class of drugs known as gliflozins. In some embodiments, the SGLT-2 inhibitor includes compounds approved as SGLT-2 inhibitors by a regulatory agency, such as the FDA or EMA. Non-limiting examples of SGLT-2 inhibitors include bexagliflozin, canagliflozin (INVOKANA®), dapagliflozin (FARXIGA®), empagliflozin (JARDIANCE®), ertugliflozin (STEGLATRO™), ipragliflozin (SUGLAT®), luseogliflozin (LUSEFI®), remogliflozin, sergliflozin, licogliflozin, sotagliflozin (ZYNQUISTA™), and tofogliflozin.

[0140] In some embodiments, the SGLT-2 inhibitor is dapagliflozin, canagliflozin, ipragliflozin, empagliflozin, bexagliflozin, licogliflozin, janagliflozin (XZP-5695), tofogliflozin, ertugliflozin, henagliflozin (SHR-3824), enavogliflozin (DWP-16001), TA-1887 (3-(4-cyclopropylbenzyl)-4-fluoro-1-(β-D-glucopyranosyl)-1H-indole), indole-N-glycoside 18 ( 3-(4-ethylbenzyl)-1-(β-D-glucopyranosyl)-1H-indole), sotagliflozin, luseogliflozin, sergliflozin etabonate (ethyl carbonate), remogliflozin, remogliflozin etabonate, and T-1095 (((2R,3S,4S,5R,6S)-6-(2-(3-(benzofuran-5-yl)propanoyl)-3-hydroxy-5-methylphenoxy)-3,4,5-trihydroxytetrahydro-2H-pyran-2-yl)etabonate).

[0141] In some embodiments, the SGLT-2 inhibitor comprises a C-glycoside such as dapagliflozin, canagliflozin, ipragliflozin, empagliflozin, bexagliflozin, licogliflozin, janagliflozin (XZP-5695), tofogliflozin, ertugliflozin, henagliflozin (SHR-3824), enavogliflozin (DWP-16001), etc. In some embodiments, the SGLT-2 inhibitor comprises a C-glycoside having a bicyclic or spiropyran group, such as tofogliflozin, ertugliflozin, and henagliflozin (SHR-3824). In some embodiments, the SGLT-2 inhibitor comprises a C-glycoside that does not have a bicyclic or spiropyran group, such as dapagliflozin, canagliflozin, ipragliflozin, empagliflozin, bexagliflozin, licogliflozin, janagliflozin (XZP-5695), and enavogliflozin (DWP-16001).

[0142] In some embodiments, the SGLT-2 inhibitor comprises an N-glycoside such as TA-1887 (3-(4-cyclopropylbenzyl)-4-fluoro-1-(β-D-glucopyranosyl)-1H-indole) and indole-N-glycoside 18 (3-(4-ethylbenzyl)-1-(β-D-glucopyranosyl)-1H-indole).

[0143] In some embodiments, the SGLT-2 inhibitor comprises a 2-methylthio-C-glycoside, such as sotagliflozin.

[0144] In some embodiments, the SGLT-2 inhibitor comprises a thiopyran-C-glycoside, such as luseogliflozin.

[0145] In some embodiments, SGLT-2 inhibitors include O-glycosides and O-glycoside prodrugs, such as sergliflozin etabonate (ethyl carbonate), remogliflozin, remogliflozin etabonate, and T-1095 (((2R,3S,4S,5R,6S)-6-(2-(3-(benzofuran-5-yl)propanoyl)-3-hydroxy-5-methylphenoxy)-3,4,5-trihydroxytetrahydro-2H-pyran-2-yl)etabonate).

[0146] SGLT-2 inhibitors include pharmaceutically acceptable salts, solvates, complexes, and salts of solvates thereof; for example, "dapagliflozin" includes salts of dapagliflozin (such as the hydrochloride salt) and solvates (such as propylene glycol hydrate); similarly, "canagliflozin" includes solvates (such as canagliflozin hemihydrate) and salts of solvates (such as the hydrochloride salt of the hydrate). Similarly, henagliflozin (SHR-3824) and dapagliflozin include complexes (such as the henagliflozin proline complex and dapagliflozin proline complex, respectively).

[0147] In some embodiments, an SGLT-2 inhibitor, as defined herein, includes any compound that exhibits SGLT-2 inhibitory activity. In some embodiments, an SGLT-2 inhibitor is selective for SGLT-2 over SGLT-1, for example, by having about 2-fold, about 5-fold, about 10-fold, about 20-fold, about 50-fold, about 100-fold, about 200-fold, about 300-fold, about 400-fold, about 500-fold, about 750-fold, about 1,000-fold, about 1,250-fold, about 1,500-fold, about 1,750-fold, about 2,000-fold, about 2,500-fold, or any value therebetween, greater activity for SGLT-2 than for SGLT-1. Exemplary SGLT-2 inhibitors have an inhibitory activity against SGLT-2 (IC) of less than about 1000 nM, less than about 500 nM, less than about 200 nM, less than about 100 nM, less than about 50 nM, less than about 25 nM, less than about 10 nM, or less than about 1 nM, as measured in the assays described herein. 50In some embodiments, the SGLT-2 inhibitor may exhibit an inhibitory activity against SGLT-2 (Icso) of less than about 25 nM, less than about 10 nM, less than about 5 nM, or less than about 1 nM, as measured by the assays described herein. An exemplary assay for determining SGLT-2 inhibitory activity is described in Ryan, et al., Kidney International, Vol. 45, pp. 48-57 (1994). Briefly, CHO cells are stably transfected with a cDNA encoding human SGLT-2 (GenBank #M95549). The cells are washed and then incubated with 10 μM [ 14 C] α-methylglucopyranoside (AMG) and 10 μM inhibitor. 14 [C]AMG uptake is quenched with cold buffer containing phlorizin, and the cells are lysed. 14 Quantify [C]AMG uptake.

[0148] SGLT-2 inhibitors include pharmaceutically acceptable salts, solvates, complexes, and salts of solvates thereof; for example, "dapagliflozin" includes salts of dapagliflozin (such as the hydrochloride salt) and solvates (such as propylene glycol hydrate); similarly, "canagliflozin" includes solvates (such as canagliflozin hemihydrate) and salts of solvates (such as the hydrochloride salt of the hydrate). Similarly, henagliflozin (SHR-3824) and dapagliflozin include complexes (such as the henagliflozin proline complex and dapagliflozin proline complex, respectively).

[0149] Exemplary SGLT-2 inhibitor formulations for use in the treatment of IgAN are described in PCT / US2008 / 057888, which is incorporated herein by reference in its entirety.

[0150] As used herein, when a subject is described as having a "controlled serum glucose level," it means that the subject has a serum glucose level within the normal or healthy range. In some embodiments, the subject has a fasting serum glucose level of about 70 mg / dL to about 130 mg / dL. For example, the subject has been determined to have a fasting serum glucose level of less than about 130 mg / dL, 125 mg / dL, 120 mg / dL, 115 mg / dL, 110 mg / dL, 105 mg / dL, 100 mg / dL, 95 mg / dL, 90 mg / dL, 85 mg / dL, 80 mg / dL, or 75 mg / dL.

[0151] As used in the methods described herein, the term "reducing" refers to a decrease in the indicated parameter relative to a baseline measurement of the same parameter in a subject obtained before the start of administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, or a decrease in the indicated parameter relative to a baseline measurement of the same parameter in a healthy subject (e.g., a subject without IgA nephropathy). Similarly, as used herein, the term "increasing" refers to an increase in the indicated parameter relative to a baseline measurement of the same parameter in a subject obtained before the start of administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, or an increase in the indicated parameter relative to a baseline measurement of the same parameter in a healthy subject (e.g., a subject without IgA nephropathy).

[0152] The term "glomerular filtration rate" (GFR) is defined as the volume of fluid filtered from the renal (kidney) glomerular capillaries into Bowman's capsule per unit time. It indicates overall kidney function. Glomerular filtration rate (GFR) can be calculated by measuring any chemical that has a steady level in the blood and is freely filtered but is neither reabsorbed nor secreted by the kidney. Thus, the measured rate is the amount of substance in urine derived from a calculable volume of blood. GFR is typically recorded in units of volume per time, e.g., milliliters per minute, and the following formula can be used: GFR = (urine concentration × urine volume) / plasma concentration. GFR can be determined by infusing inulin into plasma. Because inulin is neither reabsorbed nor secreted by the kidney after glomerular filtration, its excretion rate is directly proportional to the filtration rate of water and solutes passing through the glomerular filter. Normal values ​​are: GFR = 90-125 mL / min / 1.73 m 2 , especially GFR = 100-125 mL / min / 1.73 m 2Other principles for determining GFR include measuring 51Cr-EDTA, [125I]iothalamate, or iohexol. "Estimated glomerular filtration rate (eGFR)" is defined as derived from serum creatinine values ​​at screening, for example, based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, the Cockcroft-Gault formula, or the Modification of Diet in Renal Disease (MDRD) formula, all of which are known in the art. As used herein, "stabilizing eGFR" means slowing the rate of decline in eGFR and / or attenuating the rate of decline in eGFR. For example, the rate of decline in eGFR may be attenuated by at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95%, or any value therebetween, after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. This attenuation can extend over, for example, about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment. In some embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days. In some embodiments, the subject has been treated with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for about 6 months to about 1 year.

[0153] "ESRD" is an abbreviation for end-stage renal disease. As used herein, the onset of ESRD occurs when a subject has a blood flow rate of approximately 15 mL / min / 1.73 m 2A subject is defined as having an eGFR of less than 1 g / day and / or an eGFR of <60 at least about 3 months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0154] As used herein, "IgA nephropathy-associated disease flare" refers to a disease flare associated with worsening hematuria, proteinuria, systemic symptoms, and a decline in eGFR. Other symptoms associated with a disease flare include increased edema, fatigue, increased hematuria, gross hematuria, and other symptoms that generally adversely affect disease progression.

[0155] As used herein, when a subject is described as "maintaining potassium levels within the normal physiological range," the subject has a blood potassium level of about 3.5 mEq / L to about 5.2 mEq / L.

[0156] As used herein, when a subject is described as "maintaining sodium levels within the normal physiological range," the subject has a blood sodium level of about 135 to about 145 mEq / L.

[0157] As used herein, the term "proteinuria" refers to the presence of protein in urine above normal levels. "Proteinuria" includes "albuminuria" and "microalbuminuria." Normal human protein levels appear in urine in the range of approximately 0-30 mg / L, but in any given urine sample, levels can reach approximately 80 mg / L. For a 24-hour urine collection, normal human urinary protein levels range from approximately 0-150 mg. Proteinuria can be indicated by the urinary total protein / creatinine ratio (UPCR) or by a specific protein ratio, such as a urinary albumin / creatinine ratio (ACR) greater than approximately 30 mg / g. Typically, the urinary UACR value (mg / g) is approximately equal to the albumin excretion (mg / day) by the subject. Proteinuria, including albuminuria and microalbuminuria, often results in or is indicative of disease, but is not limited to the production of disease. Proteinuria is intended to encompass all forms of proteinuria, including, but not limited to, physiological proteinuria; functional proteinuria; and exercise proteinuria, which is associated with forms of functional proteinuria after excessive muscle exertion. Proteinuria also encompasses benign proteinuria (also known as "essential" proteinuria), which refers to types or proteinuria that are not the result of pathological changes in the kidney. Proteinuria also encompasses pathological proteinuria, e.g., levels of protein in the urine that are higher than normal physiological levels.

[0158] As used herein, the term "albuminuria" (also known as macroalbuminuria) refers to the presence of albumin in urine above normal levels. Because urinary protein is primarily albumin, normal human urinary UACR levels range from approximately 0 to 30 mg / mmol. As used herein, the term "microalbuminuria" refers to the presence of albumin in urine, which is excreted in humans at a rate of approximately 20 to 200 μg / min or at levels of approximately 30 to 300 mg / L. When defined by the urinary ACR, "microalbuminuria" refers to a urinary UACR greater than approximately 30 mg / g, or a urinary UACR of approximately 3.5 mg / mmol or greater in women and approximately 2.5 mg / mmol or greater in men. Microalbuminuria is often an early warning sign of kidney disease, but may also be present for other reasons.

[0159] As used herein, the term "hematuria" refers to the presence of blood in urine. This may manifest as gross hematuria (visible traces of blood cells) or microscopic hematuria (microscopic traces of blood) in the urine. A definitive sign of microscopic hematuria is defined as three or more red blood cells per microscopic high-power field (HPF) on a minimum of three properly collected urine samples. Microscopic hematuria can also be detected by urine dipstick (colorimetric comparison estimate) in a clinic. Hematuria (either microscopic or gross) may be asymptomatic (no additional symptoms associated with hematuria) or symptomatic. Additional symptoms include dysuria (painful urination), a feeling that the bladder is not emptying completely, or increased frequency or urination, or flank pain.

[0160] As used herein, "ALT" refers to alanine transaminase. As used herein, "AST" refers to aspartate transaminase.

[0161] Unless otherwise specified, references to amounts of endothelin receptor antagonist in this disclosure are based on the free equivalent amount of endothelin receptor antagonist. For example, 0.75 mg of atrasentan refers to 0.75 mg of atrasentan in its free form, or an equivalent amount of a salt form of atrasentan.

[0162] The present disclosure also includes combination therapies using anti-APRIL antibodies or antigen-binding fragments thereof. The antibodies described herein are exemplified using an anti-hAPRIL antibody having the amino acid sequence of SEQ ID NO: 28 for its heavy chain and the amino acid sequence of SEQ ID NO: 30 for its light chain (also referred to as VH14_1G.VL15, or BION-1301 when used in clinical trials). Optionally, the anti-APRIL antibody or antigen-binding fragment thereof is VIS649. In some cases, the anti-APRIL antibody or antigen-binding fragment thereof comprises a heavy chain complementarity determining region 1 (HC CDR1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 1, a heavy chain complementarity determining region 2 (HC CDR2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 2, a heavy chain complementarity determining region 3 (HC CDR3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 3, a light chain complementarity determining region 1 (LC CDR1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 4, a light chain complementarity determining region 2 (LC CDR2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 5, and a light chain complementarity determining region 3 (LC CDR3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 6. In some cases, the heavy and light chain CDR sequences are 95% identical to SEQ ID NOs: 1-6. In some cases, the heavy and light chain CDR sequences comprise SEQ ID NOs: 1-6. In some cases, the heavy and light chain CDR sequences consist of SEQ ID NOs: 1 to 6. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24.

[0163] In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence having at least 90%, 95%, or 99% sequence identity to SEQ ID NO: 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising the amino acid sequence of SEQ ID NO: 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22, or 24, and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 24, and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 28. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 28. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 30. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising the amino acid sequence of SEQ ID NO: 30. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 28 and a light chain comprising the amino acid sequence of SEQ ID NO: 30. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretory leader comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 32. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretory leader comprising the amino acid sequence of SEQ ID NO: 32. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain secretory leader comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 34. Optionally, the APRIL binding antibody, or antigen-binding fragment thereof, comprises a light chain secretory leader comprising the amino acid sequence of SEQ ID NO:34.In some cases, the APRIL binding antibody, or antigen-binding fragment thereof, is produced from a nucleic acid comprising one of SEQ ID NOs: 7, 9, 11, 13, 15, 17, 19, 21, or 23. In some cases, the APRIL binding antibody, or antigen-binding fragment thereof, is produced from a nucleic acid comprising SEQ ID NO: 25, 27, 29, 31, or 33.

[0164] This antibody has been shown to block the binding of human APRIL to human B-cell maturation antigen (BCMA) and transmembrane activator and calcium regulator and cyclophilin ligand interactor (TACI), significantly reducing IgA levels in healthy volunteers. This reduction in IgA levels is expected to be similar in subjects with IgA nephropathy and therefore is expected to have a significant therapeutic effect. Further characteristics and discussion of the antibodies useful in the formulations and methods described herein can be found in PCT Publication WO 2016 / 110587.

[0165] The anti-APRIL antibody or its antigen-binding fragment may be referred to as "BION-1301," which refers to an IgG4 humanized monoclonal antibody with CAS Registry Number 2642175-46-8. The disease-modifying potential of BION-1301 is mediated by blocking the binding of APRIL to its two major receptors, transmembrane activator and calcium regulator and cyclophilin ligand interactor (TACI) and B-cell maturation antigen (BCMA). Elevated APRIL levels are implicated in the pathogenesis of IgA nephropathy. Therefore, mAb-mediated neutralization of APRIL to reduce receptor activation is a promising mechanism for the treatment of IgA nephropathy. BION-1301 does not bind to BAFF (required for normal B cell maintenance), in contrast to the approved APRIL antagonist atacicept, which binds to APRIL and BAFF.

[0166] BION-1301 is being studied in adults with relapsed or refractory multiple myeloma, as well as in healthy volunteers (HVs) and adults with IgAN. Between the initiation of the BION-1301 clinical program and July 26, 2022, a total of 153 adults were enrolled in five clinical trials. Interim results from an ongoing Phase 1 / 2 clinical trial evaluating IV administration of BION-1301 450 mg Q2W in patients with IgAN demonstrated that BION-1301 treatment was well tolerated and resulted in sustained reductions in free (unbound) APRIL, Gd-IgA1, and proteinuria (as measured by reductions in UPCR). Following IV infusion, serum BION-1301 concentrations appeared comparable to those observed in healthy volunteers at the same dose and schedule. After at least 24 weeks of IV dosing, all subjects transitioned to SC dosing at 600 mg Q2W maintained similar BION-1301 exposure, biomarker responses, and reductions in proteinuria. On average, patients treated with BION-1301 demonstrated reductions in 24-hour UPCR that were evident by 3 months and continued to decline beyond 1 year, thereby providing preliminary clinical evidence of efficacy. The magnitude of the observed reductions in proteinuria are predicted to translate into clinically meaningful preservation of eGFR and significant improvements in long-term renal outcomes.

[0167] Exemplary BION-1301 formulations for use in the treatment of IgAN are described in PCT / US2021 / 035011, which is incorporated by reference herein in its entirety.

[0168] Within the context of the present disclosure, at least 90% sequence similarity should be understood to mean, in some cases, at least 95%, such as at least 99% sequence similarity.

[0169] As used herein, "sequence similarity" refers to the degree to which individual nucleotide or peptide sequences are similar. The degree of similarity between two sequences is based on the degree of identity combined with the degree of conservative changes. The percentage of "sequence similarity" is the percentage of amino acids or nucleotides that are identical or conservatively changed, i.e., "sequence similarity" = (% sequence identity) + (% conservative changes).

[0170] For the purposes of this disclosure, "conservative changes" and "identity" are considered species of the broader term "similarity." Thus, whenever the term sequence "similarity" is used, sequence "identity" and "conservative changes" are encompassed. According to certain embodiments, conservative changes are disregarded, and % sequence similarity refers to % sequence identity.

[0171] The term "sequence identity" is known to those skilled in the art. To determine the degree of sequence identity shared by two amino acid sequences or two nucleic acid sequences, the sequences are aligned for optimal comparison (e.g., gaps can be introduced into the sequence of a first amino acid or nucleic acid sequence for optimal alignment with a second amino acid or nucleic acid sequence). Such alignment can be performed over the entire length of the sequences being compared. Alternatively, alignment can be performed over a shorter comparison length, for example, over about 20, about 50, about 100 or more nucleic acids / bases or amino acids.

[0172] Subsequently, the amino acid residues or nucleotides at corresponding amino acid positions or nucleotide positions are compared. If a position in the first sequence is occupied by the same amino acid residue or nucleotide as the corresponding position in the second sequence, then the molecules are identical at that position. The degree of identity shared between sequences is typically expressed as a percentage identity between the two sequences and is a function of the number of identical positions shared by identical residues in the sequences (i.e., % identity = number of identical residues at corresponding positions / total number of positions × 100). In some cases, the two sequences being compared are of the same or substantially the same length.

[0173] The percentage of "conservative changes" can be determined similarly to the percentage of sequence identity, except that in this case, changes at specific positions in the amino acid or nucleotide sequence that are likely to preserve the functional properties of the original residues are scored as if the changes had not occurred.

[0174] With respect to amino acid sequences, relevant functional properties are the physicochemical properties of the amino acid. Conservative substitutes for an amino acid in the polypeptides of the present disclosure may be selected from other members of the class to which the amino acid belongs. For example, it is well known in the art of protein biochemistry that an amino acid belonging to a group of amino acids having a particular size or property (such as charge, hydrophobicity, and hydrophilicity) can be substituted for another amino acid without substantially altering the activity of the protein, particularly in regions of the protein not directly related to biological activity (see, for example, Watson, et al., Molecular Biology of the Gene, The Benjamin / Cummings Pub. Co., p. 224(4)). th (See, for example, the American Journal of Biological Chemistry, Vol. 1, pp. 1987-1989, 2000). For example, nonpolar (hydrophobic) amino acids include alanine, leucine, isoleucine, valine, proline, phenylalanine, tryptophan, and tyrosine. Polar neutral amino acids include glycine, serine, threonine, cysteine, tyrosine, asparagine, and glutamine. Positively charged (basic) amino acids include arginine, lysine, and histidine. Negatively charged (acidic) amino acids include aspartic acid and glutamic acid. Conservative substitutions include, for example, Arg to Lys and vice versa to maintain a positive charge, Asp to Glu to maintain a negative charge, Thr to Ser and vice versa to maintain a free -OH, and Asn to Gln and vice versa to maintain a free -NH.

[0175] In the case of nucleotide sequences, the relevant functional property is primarily the biological information that a particular nucleotide carries within the open reading frame of the sequence in relation to the transcription and / or translation machinery. It is well known that the genetic code is degenerate (or redundant), and multiple codons can carry the same information regarding the amino acid they encode. For example, in certain species, the amino acid leucine is coded for by the codons UUA, UUG, CUU, CUC, CUA, CUG (or, in the case of DNA, TTA, TTG, CTT, CTC, CTA, CTG), and the amino acid serine is specified by UCA, UCG, UCC, UCU, AGU, AGC (or, in the case of DNA, TCA, TCG, TCC, TCT, AGT, AGC). Nucleotide changes that do not change the translated information are considered conservative changes.

[0176] For purposes of this disclosure, the Basic Local Alignment Tool (BLAST) can be used to determine the percentage of identity and / or similarity between nucleotide or amino acid sequences. Queries using the BLASTn, BLASTp, BLASTx, tBLASTn, and tBLASTx programs of Altschul et al. (1990) can be submitted via the online version of BLAST, accessible at http: / / www.ncbi.nlm.nih.gov. Alternatively, a standalone version of BLAST (e.g., version 2.2.29 (released January 3, 2014)), also available for download via the NCBI internet site, can be used. BLAST queries are performed using the following parameters: To determine the percentage of identity and / or similarity between amino acid sequences: algorithm: blastp; word size: 3; scoring matrix: BLOSUM62; gap cost: presence: 11, extension: 1; composition adjustment: conditional composition score matrix adjustment; filter: off; mask: off. To determine the percentage of identity and / or similarity between nucleotide sequences: Algorithm: blastn; Word size: 11; Maximum matches within query: 0; Match / Mismatch score: 2, -3; Gap cost: Presence: 5, Extension: 2; Filter: Low complexity regions; Mask: Mask for lookup table only.

[0177] The percentage of "conservative changes" can be determined similarly to the percentage of sequence identity using the indicated algorithms and computer programs. Some computer programs, such as BLASTp, display the number / percentage of positives (= similarity) and the number / percentage of identities. The percentage of conservative changes can then be derived by subtracting the percentage of identity from the percentage of positives / similarity (percentage of conservative changes = percentage of similarity - percentage of identity).

[0178] In a further aspect, the present disclosure relates to methods of using isolated polynucleotides encoding the VH domain and / or VL domain of an antibody, or the heavy and / or light chain of an antibody according to the present disclosure. The polynucleotide sequence encoding the VH domain is optionally a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO: 13, 15, or 23 selected from the group consisting of SEQ ID NO: 7, 9, 11, 13, 15, 17, 19, 21, and 23, optionally SEQ ID NO: 23. The polynucleotide sequence encoding the VL domain is optionally a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO: 25. The polynucleotide sequence encoding the heavy chain is optionally a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO: 27. The polynucleotide sequence encoding the light chain is optionally a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO: 29.

[0179] The present disclosure further relates to an expression unit comprising several expression vectors containing several polynucleotides of the present disclosure under the control of suitable regulatory sequences, wherein the several polynucleotides encode the VH domain or heavy chain and the VL domain or light chain of an antibody of the present disclosure. The expression unit can be designed so that the polynucleotide sequence encoding the VH domain or heavy chain and the polynucleotide sequence encoding the VL domain or light chain can be present on the same expression vector. Thus, the expression unit can comprise a single vector. Alternatively, the polynucleotide sequence encoding the VH domain or heavy chain and the polynucleotide sequence encoding the VL domain or light chain can be present on different expression vectors.

[0180] A further aspect of the present disclosure relates to host cells comprising several polynucleotides of the present disclosure and / or expression units of the present disclosure, which optionally comprise an expression vector comprising both a polynucleotide sequence encoding a VH domain or heavy chain and a polynucleotide sequence encoding a VL domain or light chain.

[0181] A humanized APRIL antagonist monoclonal antibody (the anti-APRIL antibody described herein) is currently being developed for the treatment of IgAN and has undergone clinical trials in healthy volunteers (see clinicaltrials.gov NCT03945318). Blockade of APRIL with an anti-hAPRIL antibody has been shown to significantly reduce IgA and IgM, and to a lesser extent, IgG, in healthy cynomolgus monkeys, with similar results in healthy human volunteers. In addition, this blockade reduced Gd-IgA1 in healthy human volunteers. Consequently, blockade of APRIL in IgAN patients is expected to result in reduced levels of IgA, IgG, and IgM, as well as corresponding reductions in gd-IgA1, autoantibodies against gd-IgA1, immune complex deposition, and renal damage.

[0182] Myette et al. (2019, Kidney International 96(1):104-116) demonstrated the efficacy of a murine anti-APRIL antibody in a mouse model for IgA nephropathy, and the human antibody VIS649 is part of a phase 2 clinical trial (clinicaltrials.gov NCT04287985).

[0183] The term "antibody" refers to any form of antibody that exhibits a desired biological activity, such as inhibiting binding of a ligand to its receptor or inhibiting ligand-induced signaling of a receptor. In this case, the biological activity includes blocking the binding of APRIL to its receptors BCMA and / or TACI. Thus, "antibody" is used in the broadest sense and specifically encompasses, but is not limited to, monoclonal antibodies (including full-length monoclonal antibodies) and multispecific antibodies (e.g., bispecific antibodies) such as those based on Duobody® technology (Genmab) or Hexabody® technology (Genmab), or antibody fragments.

[0184] "Antibody fragment" and "antibody-binding fragment" refer to antigen-binding fragments and analogs of antibodies, which typically contain at least a portion of the antigen-binding or variable region (e.g., one or more CDRs) of the parent antibody. Antibody fragments retain at least some of the binding specificity of the parent antibody. Typically, antibody fragments retain at least 10% of the parent binding activity, expressed on a molar basis. In some cases, antibody fragments retain at least 20%, 50%, 70%, 80%, 90%, 95%, or 100% or more of the parent antibody's binding affinity for the target. Examples of antibody fragments include, but are not limited to, Fab, Fab', F(ab')2, and Fv fragments; diabodies; linear antibodies; single-chain antibody molecules, e.g., sc-Fv, unibodies (technology from Genmab); nanobodies (technology from Ablynx); domain antibodies (technology from Domantis); and multispecific antibodies formed from antibody fragments. Engineered antibody variants are reviewed in Holliger and Hudson, 2005, Nat. Biotechnol. 23:1126-1136.

[0185] A "Fab fragment" consists of one light chain and the CH1 and variable region of one heavy chain. The heavy chain of a Fab molecule cannot form disulfide bonds with another heavy chain molecule.

[0186] The "Fc" region contains two heavy chain fragments containing the CH1 and CH2 domains of an antibody. The two heavy chain fragments are held together by two or more disulfide bonds and hydrophobic interactions of the CH3 domain.

[0187] A "Fab' fragment" contains one light chain and a portion of one heavy chain containing the VH domain, the CH1 domain, and the region between the CH1 and CH2 domains, such that an interchain disulfide bond can form between the two heavy chains of two Fab' fragments to form an F(ab')2 molecule.

[0188] An "F(ab')2 fragment" contains two light chains and two heavy chains containing a portion of the constant region between the CH1 and CH2 domains, resulting in the formation of an interchain disulfide bond between the two heavy chains. Thus, an F(ab')2 fragment is composed of two Fab' fragments held together by disulfide bonds between the two heavy chains.

[0189] The "Fv region" comprises the variable regions from both the heavy and light chains, but lacks the constant regions.

[0190] A "single-chain Fv antibody" (or "scFv antibody") refers to an antibody fragment comprising the VH and VL domains of an antibody, wherein these domains are present in a single polypeptide chain. Generally, the Fv polypeptide further comprises a polypeptide linker between the VH and VL domains that enables the scFv to form the desired structure for antigen binding. For a review of scFvs, see Pluckthun, 1994, The Pharmacology of Monoclonal Antibodies, vol. 113, Rosenburg and Moore eds. Springer-Verlag, New York, pp. 269-315. See also WO 88 / 01649 and U.S. Pat. Nos. 4,946,778 and 5,260,203.

[0191] A "diabody" is a small antibody fragment having two antigen-binding sites. The fragment comprises a heavy-chain variable domain (VH) connected to a light-chain variable domain (VL) in the same polypeptide chain (VH-VL or VL-VH). By using a linker too short to allow pairing between the two domains on the same chain, the domains are forced to pair with complementary domains on another chain, generating two antigen-binding sites. Diabodies are described in more detail, for example, in EP 404,097; WO 93 / 11161; and Holliger et al., 1993, Proc. Natl. Acad. Sci. USA 90:6444-6448.

[0192] "Duobodies" are bispecific antibodies with a normal IgG structure (Labrijn et al., 2013, Proc. Natl. Acad. Sci. USA 110(13):5145-5150).

[0193] "Hexabodies" are antibodies that retain regular structure and specificity while improving killing ability (Diebolder et al., 2014, Science 343(6176):1260-3).

[0194] A "domain antibody fragment" is an immunologically functional immunoglobulin fragment containing only the variable region of a heavy chain or the variable region of a light chain. Optionally, two or more VH regions are covalently linked with a peptide linker to generate a bivalent domain antibody fragment. The two VH regions of a bivalent domain antibody fragment can target the same or different antigens.

[0195] Antibody fragments of the present disclosure may comprise a sufficient portion of the constant region to allow dimerization (or multimerization) of heavy chains with reduced disulfide bonding capacity, e.g., if at least one of the hinge cysteines normally involved in inter-heavy chain disulfide bonding is modified as described herein. In another embodiment, antibody fragments, e.g., those comprising an Fc region, retain at least one of the biological functions normally associated with the Fc region when present in an intact antibody, e.g., binding of FcRn, regulation of antibody half-life, ADCC (antibody-dependent cellular cytotoxicity) function, and / or complement fixation (e.g., if the antibody has the glycosylation profile required for ADCC function or complement fixation).

[0196] The term "chimeric" antibody refers to antibodies in which a portion of the heavy and / or light chain is identical to or homologous to corresponding sequences in antibodies derived from a particular species or belonging to a particular antibody class or subclass, while the remainder of the chain is identical to or homologous to corresponding sequences in antibodies derived from another species or belonging to another antibody class or subclass, so long as they exhibit the desired biological activity, and to fragments of such antibodies. See, e.g., U.S. Pat. No. 4,816,567 and Morrison et al., Proc. Natl. Acad. Sci. USA, Vol. 81, pp. 6851-6855 (1984).

[0197] As used herein, the term "humanized antibody" refers to forms of antibodies containing sequences derived from non-human (e.g., murine) and human antibodies. Such antibodies contain minimal sequence derived from non-human immunoglobulin. Generally, a humanized antibody will comprise substantially all of at least one, and typically two, variable domains, in which all or substantially all of the hypervariable loops correspond to those of a non-human immunoglobulin and all or substantially all of the FR regions are those of a human immunoglobulin. A humanized antibody will optionally also comprise at least a portion of an immunoglobulin constant region (Fc), typically that of a human immunoglobulin. Humanized forms of rodent antibodies essentially contain the same CDR sequences of the parent rodent antibody but can contain certain amino acid substitutions to increase affinity, to increase the stability of the humanized antibody, or for other reasons.

[0198] The antibodies of the present disclosure also include antibodies with modified (or blocked) Fc regions to provide altered effector functions. See, for example, U.S. Patent No. 5,624,821; International Publication Nos. 2003 / 086310, 2005 / 120571, and 2006 / 0057702; and Presta, Adv. Drug Delivery Rev. Vol. 58, pp. 640-656 (2006). Such modifications can be used to enhance or suppress various immune system responses, potentially with beneficial effects in diagnosis and therapy. Alterations to the Fc region include amino acid changes (substitutions, deletions, and insertions), glycosylation or deglycosylation, and the addition of multiple Fc regions. Alterations to the Fc region can also alter the half-life of the antibody in therapeutic antibodies; a longer half-life allows for less frequent administration, while also improving convenience and reducing material usage. See Presta, J. Allergy Clin. Immunol. Vol. 116, No. 731, pp. 734-35 (2005).

[0199] Antibodies of the present disclosure also include antibodies with intact Fc regions that provide complete effector functions, for example, antibodies of the IgG1 isotype that induce complement-dependent cytotoxicity (CDC) or antibody-dependent cellular cytotoxicity (ADCC) on target cells.

[0200] Antibodies can also be conjugated (e.g., covalently linked) to a molecule that improves the stability of the antibody during storage or increases the half-life of the antibody in vivo. Examples of molecules that increase half-life are albumin (e.g., human serum albumin) and polyethylene glycol (PEG). Albumin-linked and PEGylated derivatives of antibodies can be prepared using techniques well known in the art. See, e.g., Chapman, 2002, Adv. Drug Deliv. Rev. 54:531-545; Anderson and Tomasi, 1988, J. Immunol. Methods 109:37-42; Suzuki et al., 1984, Biochim. Biophys. Acta 788:248-255; and Brekke and Sandlie, 2003, Nature Rev. 2:52-62.

[0201] As used herein, the term "hypervariable region" refers to the amino acid residues of an antibody that contribute to antigen binding. Hypervariable regions are amino acid residues from the "complementarity determining regions" or "CDRs" defined by sequence alignment, e.g., residues 24-34 (L1), 50-56 (L2), and 89-97 (L3) in the light chain variable domain and residues 31-35 (H1), 50-65 (H2), and 95-102 (H3) in the heavy chain variable domain (Kabat et al., 1991, Sequences of proteins of Immunological Interest, 5th Ed. Public Health Service, National Institutes of Health, Bethesda, Md.), and / or residues from structurally defined "hypervariable loops" (HVL), e.g., residues 26-32 (L1), 50-52 (L2), and 91-96 (L3) in the light chain variable domain, and residues 26-32 (H1), 53-55 (H2), and 96-101 (H3) in the heavy chain variable domain (see Chothia and Leskl, 1987, J. Mol. Biol. 196:901-917).

[0202] "Framework" or "FR" residues or sequences are those variable domain residues or sequences other than the CDR residues as herein defined.

[0203] An antibody of the present disclosure, according to certain embodiments, may be an isolated antibody. An "isolated" antibody is one that has been identified, separated, and / or recovered from components of its natural environment. Contaminant components of its natural environment are substances that would interfere with diagnostic or therapeutic uses of the antibody, and these may include enzymes, hormones, and other proteinaceous or non-proteinaceous solutes. In some embodiments, the antibody is purified (1) to greater than 95%, and in some cases greater than 99%, by weight of the antibody, as determined by the Lowry method; (2) sufficiently to obtain at least 15 residues of N-terminal or internal amino acid sequence by use of a spinning cup sequenator; or (3) to homogeneity by SDS-PAGE under reducing or non-reducing conditions using Coomassie blue or, in some cases, silver staining. Isolated antibodies include antibodies in situ within recombinant cells, since at least one component of the antibody's natural environment will not be present. Ordinarily, however, isolated antibodies will be prepared by at least one purification step.

[0204] An "isolated" nucleic acid molecule is a nucleic acid molecule that is identified and separated from at least one contaminant nucleic acid molecule with which it is ordinarily associated in the natural source of the antibody nucleic acid. An isolated nucleic acid molecule is other than in the form or setting in which it is found in nature. Thus, isolated nucleic acid molecules are distinguished from nucleic acid molecules present in natural cells. However, isolated nucleic acid molecules include nucleic acid molecules normally contained in cells that express the antibody, e.g., the nucleic acid molecule is in a chromosomal location that is different from that of natural cells.

[0205] The term "monoclonal antibody," as used herein, refers to an antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical except for possible naturally occurring variants that may be present in minor amounts. Monoclonal antibodies are highly specific, being directed against a single antigenic site. Furthermore, in contrast to conventional (polyclonal) antibody preparations that typically include different antibodies directed against different determinants (epitopes), each monoclonal antibody is directed against a single determinant on the antigen. The modifier "monoclonal" indicates the character of the antibody as being obtained from a substantially homogeneous antibody population and is not to be construed as requiring production of the antibody by any particular method. For example, monoclonal antibodies to be used in accordance with the present disclosure may be made by the hybridoma method first described by Kohler et al., 1975, Nature 256:495, or may be made by recombinant DNA methods (see, e.g., U.S. Pat. No. 4,816,567). "Monoclonal antibodies" may also be isolated from phage antibody libraries using, for example, the techniques described in Clackson et al., 1991, Nature 352:624-628 and Marks et al., 1991, J. Mol. Biol. 222:581-597. The monoclonal antibodies herein specifically include "chimeric" antibodies.

[0206] As used herein, the term "immune cells" includes cells that are of hematopoietic origin and play a role in the immune response. Immune cells include lymphocytes such as B cells and T cells, natural killer cells, myeloid cells such as monocytes, macrophages, eosinophils, mast cells, basophils, and granulocytes.

[0207] As used herein, a sequence "variant" or "variant sequence" refers to a sequence that differs from a sequence of the present disclosure by one or more amino acid residues but retains the biological activity of the parent molecule. The present disclosure includes variants of the antibodies explicitly disclosed by different sequences. According to some embodiments, for the CDR1, CDR2, and CDR3 sequences of the VH domain, the variant sequence may contain up to six amino acid substitutions, such as 1, 2, 3, 4, 5, or 6 amino acid substitutions when the CDR1, CDR2, and CDR3 sequences are taken together. Similarly, for the CDR1, CDR2, and CDR3 sequences of the VL domain, according to some embodiments, the variant sequence may contain up to six amino acid substitutions, such as 1, 2, 3, 4, 5, or 6 amino acid substitutions when the CDR1, CDR2, and CDR3 sequences are taken together.

[0208] "Conservatively modified variants" or "conservative amino acid substitutions" are known to those skilled in the art and generally refer to amino acid substitutions that can be made without altering the biological activity of the resulting molecule. Those skilled in the art recognize that single amino acid substitutions in non-essential regions of a polypeptide generally do not substantially alter biological activity (see, e.g., Watson, et al., Molecular Biology of the Gene, The Benjamin / Cummings Pub. Co., p. 224(4 th Edition 1987).

[0209] "Specifically binds," when referring to a ligand / receptor, antibody / antigen, or other binding pair, refers to a binding reaction that is determinative of the presence of a protein, such as APRIL, in a heterogeneous population of proteins and / or other biologics. Thus, under specified conditions, a particular ligand / antigen binds to a particular receptor / antibody and does not bind in significant amounts to other proteins present in a sample.

[0210] Antibody DNA may also be modified, for example, by substituting the coding sequence for human heavy and light chain constant domains for the homologous murine sequences (U.S. Pat. No. 4,816,567; Morrison, et al., 1984, Proc. Natl. Acad. Sci. USA, 81:6851), or by covalently linking all or part of the coding sequence for non-immunoglobulin material (e.g., protein domains) to the immunoglobulin coding sequence. Typically, such non-immunoglobulin material is substituted for the constant domains of an antibody or for the variable domains of one antigen-binding site of an antibody to generate a chimeric, bivalent antibody comprising one antigen-binding site with specificity for an antigen and another antigen-binding site with specificity for a different antigen.

[0211] Amino acid sequence variants of the anti-human APRIL antibodies of the present disclosure are prepared by introducing appropriate nucleotide changes into the encoding DNA or by peptide synthesis. Such variants include, for example, deletions from, and / or insertions into, and / or substitutions of residues within the amino acid sequence shown for the anti-APRIL antibody. Any combination of deletion, insertion, and substitution can be made to arrive at the final construct, provided that the final construct possesses the desired properties. Amino acid changes can also alter post-translational processes of the anti-APRIL antibody, such as changing the number or position of glycosylation sites.

[0212] Typically, amino acid sequence variants of anti-APRIL antibodies will have an amino acid sequence that has at least 75%, optionally at least 80%, optionally at least 85%, optionally at least 90%, and optionally at least 95%, 98%, or 99% amino acid sequence similarity to the amino acid sequence of the original antibody in either the heavy or light chain, where similarity or homology with respect to this sequence is as defined above.

[0213] Antibodies with the characteristics identified herein as desirable can be screened for increased in vitro biological activity or suitable binding affinity. To screen for antibodies that bind to the same epitope on human APRIL as hAPRIL.01A, conventional cross-blocking assays, such as those described in *Antibodies, A Laboratory Manual*, Cold Spring Harbor Laboratory, Ed Harlow and David Lane (1988), can be performed. Antibodies that bind to the same epitope are likely to cross-block in such assays, but not all cross-blocking antibodies necessarily bind to the exact same epitope, because cross-blocking can result from steric hindrance of antibody binding by antibodies binding to overlapping epitopes or even nearby, non-overlapping epitopes.

[0214] Alternatively, epitope mapping, e.g., as described in Champe et al., 1995, J. Biol. Chem. 270:1388-1394, can be performed to determine whether the antibody binds to an epitope of interest. "Alanine scanning mutagenesis," as described in Cunningham and Wells, 1989, Science 244:1081-1085, or any other form of point mutagenesis of amino acid residues in human APRIL, can also be used to determine functional epitopes for anti-APRIL antibodies of the present disclosure. Another method for mapping antibody epitopes is to test antibody binding to synthetic linear and CLIPS peptides, which can be screened using the credit card format mini-PEPSCAN card, as described by Slootstra et al. (Slootstra et al., 1996, Mol. Diversity 1:87-96) and Timmerman et al. (Timmerman et al., 2007, J. Mol. Recognit. 20:283-299). Antibody binding to each peptide is determined using a PEPSCAN-based enzyme-linked immunosorbent assay (ELISA).

[0215] Additional antibodies that bind to the same epitope as hAPRIL.01A can be obtained, for example, by screening antibodies raised against APRIL for binding to the epitope, or by immunizing animals with a peptide comprising a fragment of human APRIL that contains the epitope sequence. Antibodies that bind to the same functional epitope can be expected to exhibit similar APRIL binding and similar biological activity, such as BCMA and TACI blocking activity, which can be confirmed by functional assays of the antibody.

[0216] The antibody can be selected from any class of immunoglobulin, including IgM, IgG, IgD, IgA, and IgE. In some cases, the antibody is an IgG antibody. Any isotype of IgG can be used, including IgG1, IgG2, IgG3, and IgG4. Variants of IgG isotypes are also contemplated. The antibody can contain sequences from more than one class or isotype. Optimization of the constant domain sequence required to generate the desired biological activity is readily accomplished by screening the antibodies using biological assays known in the art or described herein.

[0217] Similarly, any class of light chain can be used in the compositions and methods herein. In particular, kappa, lambda, or variants thereof are useful in the compositions and methods of the present invention.

[0218] The antibodies and antibody fragments of the disclosure may also be administered with a cytotoxic payload, such as a cytotoxic agent or a radionucleotide, such as 99Tc, 90Y, 111In, 32P, 14C, 125I, 3H, 131I, 11C, 150, 13N, 18F, 35S, 51Cr, 57To, 226Ra, 60Co, 59Fe, 57Se, 152Eu, 67Cu, 217Ci, 211At, 212Pb, 47Sc, 109Pd, 234 Th, and 40K, 157Gd, 55Mn, 52Tr, and 56Fe. Such antibody conjugates can be used in immunotherapy to selectively target and kill cells that express the target (the antibody's antigen) on their surface. Exemplary cytotoxic agents include ricin, vinca alkaloids, methotrexate, Pseudomonas exotoxin, saporin, diphtheria toxin, cisplatin, doxorubicin, abrin toxin, gelonin, and pokeweed antiviral protein.

[0219] The antibodies and antibody fragments of the present disclosure may also be conjugated to fluorescent or chemiluminescent labels, including fluorophores, such as rare earth chelates, fluorescein and its derivatives, rhodamine and its derivatives, isothiocyanates, phycoerythrin, phycocyanin, allophycocyanin, o-phthalaldehyde, fluorescamine, 152Eu, dansyl, umbelliferone, luciferin, luminal labels, isoluminal labels, aromatic acridinium ester labels, imidazole labels, acridimium salt labels, oxalate ester labels, aequorin labels, 2,3-dihydrophthalazinedione, biotin / avidin, spin labels, and stable free radicals.

[0220] Any method known in the art may be used to conjugate the antibody or protein molecules of the present disclosure to various moieties, including those described by Hunter et al., 1962, Nature 144:945; David et al., 1974, Biochemistry 13:1014; Pain et al., 1981, J. Immunol. Meth. 40:219; and Nygren, J., 1982, Histochem. And Cytochem. 30:407. Methods for conjugating antibodies and proteins are conventional and well known in the art.

[0221] Various aspects of the disclosure are described in further detail in the following subsections.

[0222] B. Treatment method In normal and healthy human kidneys, ET-1 and ET-RA expression is stronger in vascular tissue and weaker in glomerular structures. In contrast, subjects with IgAN show increased expression of ET-1 and ET-RA in the kidney. In this population, ET-1 expression is positively correlated with proteinuria, which is at least partially ameliorated by the administration of ACE inhibitors. In fact, the current treatment for IgAN is the optimization of antihypertensive and antiproteinuric agents (e.g., angiotensin-converting enzyme inhibitors and / or angiotensin II receptor blockers) in conjunction with a course of corticosteroids to inhibit disease progression. See, for example, Penfold et al., Int. J. Nephrol. And Renovascular Dis. 11, pp. 137-148 (2017). However, the combination of these drugs can have significant dose-limiting side effects, such as hyperkalemia, and in more severe cases, additional immunosuppression may be required.

[0223] Clinically, IgAN is diagnosed by renal biopsy demonstrating the presence of mesangial cell proliferation and / or matrix proliferation (or advanced focal segmental glomerulosclerosis) with predominantly IgA (≥2+) mesangial granular deposition on immunofluorescence. This pathology differs from other progressive renal diseases, such as diabetic nephropathy, which typically presents with diffuse capillary basement membrane thickening with peripheral hyaline PAS-positive nodules, segmental or global glomerulosclerosis in advanced stages, and thickened arterioles with hyaline deposits. See, e.g., Zanatta, et al., Renal Failure, 34(3), pp. 308-315 (2012).

[0224] Thus, in some embodiments, a method of treating IgA nephropathy is provided, comprising administering an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof. In some embodiments, administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL-binding antibody, or antigen-binding fragment thereof, provides a synergistic effect, such as those described herein.

[0225] In some embodiments, there is provided a combination therapy of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, for treating IgA nephropathy in a subject in need thereof.

[0226] In some cases, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is selected from the group consisting of tezosentan, spysentan, bosentan, sparsentan, macitentan, ambrisentan, sitaxsentan, atriopeptin, atrasentan, and pharmaceutically acceptable salts of any of the foregoing, and combinations thereof. In some cases, the endothelin receptor is atrasentan, or a pharmaceutically acceptable salt thereof. In some cases, the endothelin receptor is sparsentan, or a pharmaceutically acceptable salt thereof.

[0227] In some embodiments, methods are provided for treating IgA nephropathy in a subject in need thereof, comprising administering to the subject atrasentan, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof. In some embodiments, methods are provided for treating IgA nephropathy in a subject in need thereof, comprising administering to the subject sparsentan, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof.

[0228] In some embodiments, provided are methods of treating IgA nephropathy in a subject in need thereof, comprising administering atrasentan, or a pharmaceutically acceptable salt thereof, and BION-1301 to the subject. In some embodiments, provided are methods of treating IgA nephropathy in a subject in need thereof, comprising administering sparsentan, or a pharmaceutically acceptable salt thereof, and BION-1301 to the subject.

[0229] In some cases, the sequences shown in the sequence listing relate to the VH and VL domains of anti-APRIL antibodies, including the heavy and light chain amino acid sequences and encoding DNA sequences of the antibodies described herein, for the formulations and methods described herein. Additionally, the amino acid sequences of the CDRs of both the heavy and light chains of the antibodies described herein are provided. Table 1 below correlates the sequence IDs with their respective sequences.

[0230] [Table 1]

[0231] [Table 2]

[0232] [Table 3]

[0233] [Table 4]

[0234] [Table 5]

[0235] [Table 6]

[0236] [Table 7]

[0237] [Table 8]

[0238] Anti-APRIL antibodies have previously been described in U.S. Patent Application Publication No. 2021 / 0379183.

[0239] Various dosing schedules can be used, as described below. In certain embodiments, the method involves repeating infusions or subcutaneous administration on a weekly ("QW") schedule for multiple cycles (e.g., 4, 6, 8 weeks, etc.). In other embodiments, the method involves repeating infusions or subcutaneous administration on a schedule of at least once every two weeks ("biweekly as used herein" or "Q2W") schedule for multiple cycles (e.g., 4, 6, 8 weeks, etc.). Alternatively, the method involves repeating infusions or subcutaneous administration on a schedule of at least once every four weeks ("Q4W") or once a month ("QMT") schedule for multiple cycles (e.g., 8, 12, 16 weeks, etc.). In certain embodiments, a frontloading dosing schedule is used. The term "frontloading" when referring to the administration of an active agent refers to an initial loading dose followed by a maintenance dose. The initial loading dose(s) is intended to more rapidly increase the serum active agent concentration in an animal or human patient to an effective target serum concentration. In various embodiments, front loading is achieved by an initial administration delivered over a period of 3 weeks or less to allow the antibody to reach a target serum concentration. Preferably, the loading dose or series of doses is administered over a period of 2 weeks or less, more preferably 1 week or less, e.g., 1 day or less. Most preferably, the loading dose is a single administration, followed by no maintenance dose for at least 1 week, and the loading dose is administered over a period of 1 day or less. To avoid adverse immune responses to the antibody active agent, it may be preferable to deliver the loading dose of the antibody administered by intravenous injection. The present disclosure includes loading and maintenance doses of front-loaded active agents delivered by intravenous or subcutaneous administration.

[0240] The administration of the loading dose may be, for example, one or more administrations spaced at least about 1, 2, 3, 4, 5, 6, 7, or 8 weeks apart. In some embodiments, at least one loading dose is administered by one or more intravenous injections, followed by at least one maintenance dose by one or more intravenous or subcutaneous administrations. In other embodiments, the instructions may be for administering, for example, at least one loading dose by one or more intravenous or subcutaneous administrations and at least one maintenance dose by one or more intravenous or subcutaneous administrations. In certain embodiments, both the at least one loading dose and the at least one maintenance dose are administered subcutaneously. In other embodiments, at least one loading dose is administered by intravenous infusion, followed by at least one maintenance dose by subcutaneous administration. For example, a method of treatment may include administering a loading dose of 150 to 1350 mg of an APRIL-binding antibody, or antigen-binding fragment thereof, e.g., BION-1301, by intravenous infusion or subcutaneous injection. Following the loading dose (e.g., 1 week, 2 weeks, 3 weeks, or 4 weeks after the loading dose), a maintenance dose of 600 mg or less of an APRIL-binding antibody, or antigen-binding fragment thereof, e.g., BION-1301, may be administered by subcutaneous injection no more than once every 4 weeks, preferably no more than once every 3 weeks, more preferably no more than once every 2 weeks, and in embodiments no more than once every week.

[0241] The loading dose of the active agent may be larger than the subsequent maintenance dose (e.g., about 1.5-fold, 2-fold, 3-fold, 4-fold, or 5-fold larger). The one or more therapeutically effective maintenance doses may be any therapeutically effective amount described herein. The loading dose may be about 2 or 3 times larger than the maintenance dose. The active agent may be administered in two (or more) loading doses prior to the maintenance dose. A first loading dose of the antibody or fragment thereof may be administered on day 1, a second loading dose may be administered, for example, about 1 or 2 weeks later, and maintenance doses may be administered thereafter, for example, weekly or biweekly, over the treatment period. The first loading dose may be about 3 or 4 times larger than the maintenance dose, and the second loading dose may be about 2, 3, 4, 5, or more times larger than the maintenance dose.

[0242] In one example, a loading dose schedule comprising administration by either intravenous infusion or subcutaneous administration repeated at least once every two weeks for up to at least four weeks is followed by a maintenance dose schedule comprising administration by either intravenous infusion or subcutaneous administration, where the maintenance dose schedule results in lower amounts of anti-APRIL antibody administered, either by each dose comprising less anti-APRIL antibody or by administering the antibodies at longer intervals than during the loading dose schedule. In another example, a loading dose schedule comprising administration by either intravenous infusion or subcutaneous administration repeated at least once daily, more preferably twice daily, for up to at least four days is followed by a maintenance dose schedule comprising administration by either intravenous infusion or subcutaneous administration, such as a QW, Q2W, Q4W, QM, etc. schedule. In one embodiment, the loading dose schedule comprises administering the antibody by intravenous infusion, and the maintenance dose schedule comprises administering the antibody by subcutaneous injection. In another embodiment, both the loading dose schedule and the maintenance dose schedule comprise administering the antibody by subcutaneous injection. In another embodiment, both the loading dose schedule and the maintenance dose schedule comprise administering the antibody by intravenous infusion. This is not meant to be an exhaustive list of dosing schedules.

[0243] By way of example only, the subcutaneous injection of the method involves administering about 2 mL of the antibody formulation to a patient at a preferred injection site (e.g., thigh, abdomen, upper arm, etc.). In a preferred embodiment, the anti-APRIL antibody of the formulation is at a concentration of about 150 mg / mL, resulting in a single injection of about 300 mg of anti-APRIL antibody. In a specific embodiment, the subcutaneous injection of the method involves administering about 4 mL (as a single injection or as two 2 mL injections) of an antibody formulation of anti-APRIL antibody at a concentration of about 150 mg / mL, resulting in a dose of about 600 mg of anti-APRIL antibody. The dose, and the number of injections required as part of a single administration, can be adjusted as needed to achieve a total desired dose of anti-APRIL antibody of about 10 mg to about 1350 mg.

[0244] In certain other embodiments, the intravenous infusion of the method comprises (a) diluting a formulation of the first aspect of the disclosure and embodiments thereof to a concentration of about 0.1 mg / mL to about 10 mg / mL in 0.9% saline, and (b) administering a total dose of about 10 mg to about 1350 mg of anti-APRIL antibody to the individual in a single intravenous administration of the diluted formulation over a period of about 2 hours. Again, by way of example only, about 15 mL of a formulation having an anti-APRIL antibody concentration of about 20 mg / mL is added to about 235 mL of 0.9% saline to provide an intravenous dose at a concentration of about 1.2 mg / mL.

[0245] In certain embodiments, methods of administering an anti-APRIL antibody to an individual in need thereof comprise administering a formulation described herein via a loading / maintenance administration protocol. Such a protocol may comprise a loading component of the protocol comprising one or more administrations of the anti-APRIL antibody at a concentration higher than the anti-APRIL antibody concentration in the maintenance component of the loading / maintenance administration protocol; one or more administrations of the anti-APRIL antibody at a frequency higher than the frequency of administration of the anti-APRIL antibody in the maintenance component of the loading / maintenance administration protocol; and / or one or more administrations of the anti-APRIL antibody by a route of administration that is different from the route of administration of the anti-APRIL antibody in the maintenance component of the loading / maintenance administration protocol.

[0246] By way of example only, the loading component of a loading / maintenance administration protocol may comprise one or more intravenous administrations of an anti-APRIL antibody, and the maintenance component of a loading / maintenance administration protocol may comprise one or more subcutaneous administrations of an anti-APRIL antibody. In such examples, the concentration of the loading dose may be higher than that used in the maintenance dose, and / or the administration frequency may be greater than that used in the maintenance dose.

[0247] In another example, the loading component of the loading / maintenance protocol may comprise one or more subcutaneous administrations of an anti-APRIL antibody, and the maintenance component of the loading / maintenance protocol may comprise one or more intravenous administrations of an anti-APRIL antibody. In such an example, the concentration of the loading dose may be higher than that used in the maintenance dose, and / or the administration frequency may be greater than that used in the maintenance dose.

[0248] In another example, the loading component of the loading / maintenance administration protocol may comprise one or more subcutaneous administrations of an anti-APRIL antibody, and the maintenance component of the loading / maintenance administration protocol may comprise one or more subcutaneous administrations of an anti-APRIL antibody. In such an example, the concentration of the loading dose may be higher and / or the administration frequency may be higher than the concentration used in the maintenance dose.

[0249] In one embodiment, the loading dose comprises an intravenous infusion of 150 to 1350 mg of anti-APRIL antibody, with at least one subsequent infusion of that amount at a first time interval, and the maintenance dose comprises administering either: i) a smaller amount of anti-APRIL antibody administered at a first time interval after the last loading dose infusion, with that smaller amount and at least one subsequent administration at the same time interval for at least 12 weeks; ii) the same amount of anti-APRIL antibody administered at a second time interval after the last loading dose infusion, with that same amount and at least one subsequent administration at a second time interval for at least 12 weeks, the second time interval being longer than the first time interval; or iii) a smaller amount of anti-APRIL antibody administered at a second time interval after the last loading dose infusion, with that same amount and at least one subsequent administration at the second time interval for at least 12 weeks; and the maintenance administration may be by intravenous infusion or subcutaneous injection, preferably by subcutaneous injection. In one embodiment, the loading dose comprises a subcutaneous injection of 150 to 1350 mg of anti-APRIL antibody, followed by at least one subsequent subcutaneous injection of that amount at a first time interval; and the maintenance dose comprises administering either: i) a smaller amount of anti-APRIL antibody administered at a first time interval after the last loading dose injection, followed by at least one subsequent administration of that smaller amount at the same time interval for at least 12 weeks; ii) the same amount of anti-APRIL antibody administered at a second time interval after the last loading dose injection, followed by at least one subsequent administration of that same amount at a second time interval for at least 12 weeks, the second time interval being longer than the first time interval; or iii) a smaller amount of anti-APRIL antibody administered at a second time interval after the last loading dose injection, followed by at least one subsequent administration of that same amount at a second time interval for at least 12 weeks; and the maintenance administration may be by intravenous infusion or subcutaneous injection.

[0250] In certain embodiments, the subject has been determined to have a controlled serum glucose level. In some embodiments, the subject with the controlled serum glucose level is not being treated for diabetes. In some embodiments, the subject with the controlled serum glucose level is being treated for diabetes. In some embodiments, the subject with the controlled serum glucose level is not being treated for type 2 diabetes. In some embodiments, the subject with the controlled serum glucose level is being treated for type 2 diabetes. In some embodiments, the subject has been determined to have a controlled serum glucose level. For example, the subject has been determined to have a fasting serum glucose level of less than about 130 mg / dL, about 125 mg / dL, about 120 mg / dL, about 115 mg / dL, about 110 mg / dL, about 105 mg / dL, about 100 mg / dL, about 95 mg / dL, about 90 mg / dL, about 85 mg / dL, about 80 mg / dL, or about 75 mg / dL, or any value therebetween.

[0251] In another aspect, provided herein is a method for inhibiting mesangial cell activation in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof. In some cases, inhibiting mesangial cell activation comprises reducing the activity of one or more biomarkers indicative of mesangial cell inflammation and / or mesangial cell proliferation. Reducing mesangial cell inflammation comprises reducing the expression and / or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation. In some cases, inhibiting mesangial cell activation comprises reducing a pro-fibrotic response in mesangial cells. In some cases, mesangial activation is induced by IgA immune complexes. In some cases, mesangial activation is associated with the presence of IgA immune complexes.

[0252] In some embodiments, nephritis in a subject with IgA nephropathy is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's nephritis is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0253] In some embodiments, renal fibrosis in a subject with IgA nephropathy is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's renal fibrosis is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0254] In some embodiments, renal fibrosis in a subject with IgA nephropathy is reduced to less than about 50% of the affected renal cortical area after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's renal fibrosis is reduced to less than about 40% of the cortical area. For example, in some embodiments, the subject's renal fibrosis is reduced to less than about 35%, about 30%, about 25%, about 20%, about 15%, or about 10% of the cortical area, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0255] In another aspect, provided herein is a method for reducing the incidence of hematuria in a subject with IgA nephropathy, the method comprising administering an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, each as described herein.

[0256] In some embodiments, the number of urinary red blood cells per high-power (microscopic) field (rbc / hpf) in subjects with IgA nephropathy is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's urinary RBC / HPF is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0257] In another aspect, provided herein is a method for stabilizing eGFR in a subject with IgA nephropathy, the method comprising administering an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0258] In some embodiments, provided herein are methods for reducing the rate of decline in eGFR in a subject with IgA nephropathy, the methods comprising administering an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the subject's rate of decline in eGFR is reduced by at least about 10% following treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, following treatment). In some embodiments, the subject's eGFR declines by at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days. In certain of the above embodiments, the subject has been treated with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for about 6 months to about 1 year.

[0259] In some embodiments, the rate of decline in eGFR in a subject with IgA nephropathy is about 10 mL / min / 1.73 m after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. 2For example, after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment. In certain embodiments, the subject's rate of decline in eGFR is about 9 mL / min / 1.73 m after about 6 months to about 1 year of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. 2 , approximately 8 mL / min / 1.73 m 2 , about 7mL / min / 1.73m 2 , approximately 6 mL / min / 1.73 m 2 , about 5mL / min / 1.73m 2 , approximately 4 mL / min / 1.73 m 2 , about 3mL / min / 1.73m 2 , about 2mL / min / 1.73m 2 , about 1mL / min / 1.73m 2 , or approximately 0.75 mL / min / 1.73 m 2 For example, a typical age-related decline in eGFR in subjects between about 20 and about 30 years of age is about 1 mL / min / 1.73 m 2 / year.

[0260] In another aspect, provided herein are methods for reducing the number of IgA nephropathy-associated disease flares in a subject with IgA nephropathy, comprising administering to a subject in need thereof an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof. In some embodiments, the method reduces disease flares associated with hematuria. In some embodiments, the method reduces disease flares associated with proteinuria. In some embodiments, the method reduces IgA nephropathy-associated disease flares associated with systemic symptoms. In some embodiments, the method reduces a decline in eGFR as described anywhere herein. In some embodiments, the method reduces one or more of edema, fatigue, hematuria, or gross hematuria. In some embodiments, the method positively impacts disease progression.

[0261] In another aspect, provided herein is a method for delaying the onset of ESRD in a subject with IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0262] In some embodiments, the methods include diagnosing IgA nephropathy in a subject and determining whether the subject's eGFR is 15 mL / min / 1.73 m 2 In certain embodiments, the method increases the time between a diagnosis of IgA nephropathy in a subject and the time the subject's eGFR drops below 15 mL / min / 1.73 m. 2 For example, in some embodiments, the method increases the time between a diagnosis of IgA nephropathy in a subject and the time the subject's eGFR drops below 15 mL / min / 1.73 m by at least about 10%. 2 The time between the time the concentration drops below 100%, is increased by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 100%, about 150%, about 200%, about 250%, about 300%, about 350%, about 400%, about 450%, or about 500%, or any value therebetween.

[0263] In certain embodiments, the method comprises diagnosing IgA nephropathy in a subject and determining whether the subject's eGFR is 15 mL / min / 1.73 m 2 For example, the method may increase the time between when the subject's eGFR drops below 15 mL / min / 1.73 m for at least about 1 year. 2 The time for the blood pressure to decrease to below 100 ppm can be delayed by at least about 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7 years, 7.5 years, 8 years, 8.5 years, 9 years, 9.5 years, 10 years, 11 years, 12 years, 13 years, 15 years, 16 years, 17 years, 18 years, 19 years, or 20 years.

[0264] In another aspect, provided herein is a method for reducing proteinuria in a subject with IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0265] In some embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In some embodiments, the amount of protein in the subject's urine is reduced by at least about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0266] In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by about 20% to about 80% after about 2 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by about 20% to about 80% after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain of these embodiments, the amount of protein in the urine of the subject is reduced by about 25% to about 80%. In certain of these embodiments, the amount of protein in the urine of the subject is reduced by about 30% to about 80%. In certain of these embodiments, the amount of protein in the urine of the subject is reduced by about 35% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 40% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 45% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 50% to about 80%. In the foregoing embodiments, the reduction in the amount of protein (e.g., albumin) in the subject's urine is relative to the amount of protein (e.g., albumin) in the urine of the subject with IgA nephropathy prior to initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0267] In some embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by about 100 mg / dL to about 3,000 mg / dL after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 2,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 2,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 1,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 1,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 400 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 300 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 200 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 2,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 2,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 1,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 1,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 900 mg / dL.In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 800 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 600 mg / dL to about 900 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 700 mg / dL to about 900 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 1,000 mg / dL to about 2,000 mg / dL. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days. In the foregoing embodiments, the reduction in the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine before initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0268] In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by about 100 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of a subject is reduced by about 200 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of a subject is reduced by about 300 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In the foregoing embodiments, the reduction in the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine before initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0269] In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced by about 500 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of a subject is reduced by about 600 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of a subject is reduced by about 700 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In the foregoing embodiments, the reduction in the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine before initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0270] In some embodiments, a subject with IgA nephropathy has a reduction in urinary protein (e.g., albumin) levels of less than about 1.0 gram / day after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 20 weeks, 30 weeks, 40 weeks, 50 weeks, 60 weeks, 70 weeks, 80 weeks, 90 weeks, 100 weeks, 110 weeks, 120 weeks, 130 weeks, 140 weeks, 150 weeks, 160 weeks, 170 weeks, 180 weeks, 190 weeks, or 200 weeks after treatment). In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.9 gram / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.8 gram / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.7 grams / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.6 grams / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.5 grams / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.4 grams / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.3 grams / day. In certain embodiments, the subject has a reduction in urinary protein levels of less than about 0.2 grams / day. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days. In the foregoing embodiments, the reduction in the amount of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine before initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0271] In another aspect, provided herein is a method for reducing fatigue in a subject with IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0272] In some embodiments, fatigue in a subject with IgA nephropathy is reduced by about 5% to about 80% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, fatigue is reduced by about 10% to about 75%. In certain embodiments, fatigue is reduced by about 10% to about 70%. In certain embodiments, fatigue is reduced by about 10% to about 65%. In certain embodiments, fatigue is reduced by about 10% to about 60%. In certain embodiments, fatigue is reduced by about 10% to about 55%. In certain embodiments, fatigue is reduced by about 10% to about 50%. In certain embodiments, fatigue is reduced by about 10% to about 45%. In certain embodiments, fatigue is reduced by about 10% to about 40%. In certain embodiments, fatigue is reduced by about 10% to about 35%. In certain embodiments, fatigue is reduced by about 10% to about 30%. In certain embodiments, fatigue is reduced by about 10% to about 25%. In certain embodiments, fatigue is reduced by about 10% to about 20%. In certain embodiments, fatigue is reduced by about 10% to about 15%. In certain embodiments, fatigue is reduced by about 20% to about 75%. In certain embodiments, fatigue is reduced by about 20% to about 70%. In certain embodiments, fatigue is reduced by about 20% to about 65%. In certain embodiments, fatigue is reduced by about 20% to about 60%. In certain embodiments, fatigue is reduced by about 20% to about 55%. In certain embodiments, fatigue is reduced by about 20% to about 50%. In certain embodiments, fatigue is reduced by about 20% to about 45%. In certain embodiments, fatigue is reduced by about 20% to about 40%. In certain embodiments, fatigue is reduced by about 20% to about 35%. In certain embodiments, fatigue is reduced by about 20% to about 30%. In certain embodiments, fatigue is reduced by about 30% to about 75%.In certain embodiments, fatigue is reduced by about 30% to about 70%. In certain embodiments, fatigue is reduced by about 30% to about 65%. In certain embodiments, fatigue is reduced by about 30% to about 60%. In certain embodiments, fatigue is reduced by about 30% to about 55%. In certain embodiments, fatigue is reduced by about 30% to about 50%. In certain embodiments, fatigue is reduced by about 30% to about 45%. In certain embodiments, fatigue is reduced by about 30% to about 40%. In certain embodiments, fatigue is reduced by about 40% to about 75%. In certain embodiments, fatigue is reduced by about 40% to about 70%. In certain embodiments, fatigue is reduced by about 40% to about 65%. In certain embodiments, fatigue is reduced by about 40% to about 60%. In certain embodiments, fatigue is reduced by about 40% to about 55%. In certain embodiments, fatigue is reduced by about 40% to about 50%. In certain embodiments, fatigue is reduced by about 50% to about 75%. In certain embodiments, fatigue is reduced by about 50% to about 70%. In certain embodiments, fatigue is reduced by about 50% to about 65%. In certain embodiments, fatigue is reduced by about 50% to about 60%. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days. In certain embodiments, the reduction in fatigue comprises a decrease in score on one or more of the Fatigue Severity Scale, the Chalder Fatigue Scale, the FACIT Fatigue Scale, the Brief Fatigue Inventory, the FACT-F subscale, general energy and impact, the May and Kline Adjective Checklist, the Pearson-Byars Fatigue Checklist, the Rhoten Fatigue Scale, the Schedule for Fatigue and Anergy, a visual analog scale, or a personal fitness checklist. In the foregoing embodiments, the reduction in fatigue experienced by the subject with IgA nephropathy is relative to the fatigue experienced by the subject prior to initiation of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the reduction in fatigue comprises a reduction in the score on a Brief Fatigue Inventory.

[0273] Target Selection Subjects with IgA nephropathy described anywhere herein may be diagnosed using one or more methods known in the art. Non-limiting examples include: kidney biopsy, detection of galactose-deficient IgA (e.g., Gd-IgA1), detection of anti-glycan antibodies, detection of IgA immune complex deposition in the kidney, or any combination of the foregoing. In some embodiments, diagnosing IgA nephropathy involves detecting IgA immune complex deposition in the kidney. In certain embodiments, diagnosing IgA nephropathy involves kidney biopsy. In certain embodiments, diagnosing IgA nephropathy involves detecting galactose-deficient IgA. In certain embodiments, diagnosing IgA nephropathy involves detecting anti-glycan antibodies (e.g., KM55). In certain embodiments, diagnosing IgA nephropathy involves kidney biopsy followed by detection of IgA immune complex deposition in the kidney (e.g., by light microscopy and / or immunofluorescence microscopy).

[0274] In some embodiments, the presence and / or level of a particular protein in a subject is determined prior to administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof. For example, serum levels of Gd-IgA1, serum levels of Gd-IgA1-specific autoantibodies, and / or serum and / or urine levels of IgA1-containing immune complexes. See, e.g., Knoppova, et al., Front. Immunol., Vol. 17, Art. 117 (2016). In some embodiments, the subject has a Gd-IgA level at or above the 90th percentile prior to administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof. In some embodiments, the subject has a Gd-IgA level at or above the 95th percentile prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject's Gd-IgA level decreases to below the 90th percentile after about 6 months to 1 year of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0275] In certain embodiments, the subject has mesangial cellularity in about ≧50% (e.g., about ≧60%, about ≧70%, or about ≧80%) of the glomeruli, where mesangial cellularity is defined as more than four mesangial cells in any mesangial region of the glomerulus. In certain embodiments, the subject has intratubular hypercellularity, where intratubular hypercellularity is defined as hypercellularity resulting from an increased number of cells within the lumen of the glomerular capillaries. In certain embodiments, the subject has segmental sclerosis, where segmental sclerosis is defined as adhesions or sclerosis (occlusion of the capillary lumen by a matrix) in some, but not all, of the glomerular tuft. In certain embodiments, the subject has tubular atrophy / interstitial fibrosis in about ≧50% (e.g., about ≧60%, about ≧65%, about ≧70%, about ≧75%, or about ≧80%) of the cortical area, where tubular atrophy / interstitial fibrosis is defined as the estimated percentage of the cortical area that exhibits tubular atrophy or interstitial fibrosis. In certain embodiments, the subject has crescents present on glomeruli. In certain of these embodiments, the subject has crescents present in less than about 25% (e.g., less than about 20%, about 15%, about 10%, or about 5%) of the glomeruli. In certain embodiments, the subject has a MEST-C score of M1; E1; S1; T1 or T2; and / or C0 or C1 under the Oxford MEST-C classification system. The Oxford MEST-C classification system is defined in Kidney International (2009) 76, 546-556 and Nature Reviews Nephrology (2017) 13, 385-386 (see also: Kidney Research and Clinical Practice (2016) 35, 197-203; and IgA Nephropathy in Medscape (accessed November 4, 2019)).

[0276] In some embodiments, the subject is at high risk of progressing to ESRD. In certain of these embodiments, the subject has excreted an average of about 1 gram or more of protein in the urine per day for at least about 3 months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the subject has an average eGFR of ≦60 mL / min / 1.73 m for at least about 3 months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 (e.g., about ≦55, about ≦50, about ≦45, about ≦40, about ≦35). In certain of these embodiments, the subject has an eGFR >30 mL / min / 1.73 m prior to the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 It has.

[0277] In some embodiments, the subject is excreting an average of about 1 gram or more of protein in the urine per day for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, a subject may excrete an average of 1.1 grams, 1.2 grams, 1.3 grams, 1.4 grams, 1.5 grams, 1.6 grams, 1.7 grams, 1.8 grams, 1.9 grams, 2.0 grams, 2.1 grams, 2.2 grams, 2.3 grams, 2.4 grams, 2.5 grams, 2.6 grams, 2.7 grams, 2.8 grams, 2.9 grams, 3.0 grams, 3.1 grams, 3.2 grams, 3.3 grams, 3.4 grams, 3.5 grams, 5 grams, or 7.5 grams, or 10 grams of protein in their urine per day, or any value therebetween, for at least about three months prior to the first administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0278] In some embodiments, the subject excretes an average of about 0.3 grams to about 2 grams of protein in the urine per day for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject may excrete about 0.3 grams to 0.5 grams, 0.5 grams to 1 gram, about 0.5 grams to 1.5 grams, about 1 gram to 1.5 grams, or about 1.5 grams to 2 grams of protein in the urine per day for at least 3 months.

[0279] In some embodiments, the subject excretes at least about 1 gram of protein in the urine per day for at least two of three consecutive measurements one year prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, a subject may excrete about 1.1 grams, 1.2 grams, 1.3 grams, 1.4 grams, 1.5 grams, 1.6 grams, 1.7 grams, 1.8 grams, 1.9 grams, 2.0 grams, 2.1 grams, 2.2 grams, 2.3 grams, 2.4 grams, 2.5 grams, 2.6 grams, 2.7 grams, 2.8 grams, 2.9 grams, 3.0 grams, 3.1 grams, 3.2 grams, 3.3 grams, 3.4 grams, 3.5 grams, 5 grams, or 7.5 grams, or 10 grams of protein per day, or any value therebetween, in their urine for at least two of three consecutive measurements, one year prior to the first administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0280] In some embodiments, the subject has a UACR of at least about 300 mg / g, e.g., 300 mg / g to about 5,000 mg / g, for at least three months prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has a UACR of about 800 mg / g, e.g., 800 mg / g to about 5,000 mg / g, for at least three months prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has a UACR value of at least about 500 mg / g, about 600 mg / g, about 700 mg / g, about 800 mg / g, about 900 mg / g, about 1,000 mg / g, about 1,500 mg / g, about 2,000 mg / g, about 2,500 mg / g, about 3,000 mg / g, about 3,500 mg / g, about 4,000 mg / g, about 4,500 mg / g, or about 5,000 mg / g, or any value therebetween, for at least three months prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0281] In some embodiments, the subject has a decrease in UACR of at least about 30% relative to the subject's mean UACR value for at least three months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, e.g., a decrease of about 30% to about 100% relative to the subject's mean UACR value for at least three months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has a decrease in UACR of at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 100%, or any value therebetween, relative to the subject's mean UACR value for at least three months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, subjects with a decreased UACR value also do not experience significant sodium retention and / or significant fluid retention. In some embodiments, significant fluid retention can be about 1 kg to about 4 kg over a 6-week period, for example, about 4 kg, about 3.5 kg, about 3 kg, about 2.5 kg, about 2 kg, about 1.5 kg, or about 1 kg over a 6-week period, or any value therebetween. In some embodiments, subjects with significant fluid retention exhibit clinical symptoms of edema.

[0282] In certain embodiments, the subject receives a blood glucose level of about 20 to about 90 mL / min / 1.73 m for at least about 3 months (e.g., about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 12 months, about 1.5 years, or about 2 years) prior to the first administration of the endothelin receptor antagonist, or pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 For example, for at least about 3 months prior to the first administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, the patient has a mean eGFR of about 20 to about 50 mL / min / 1.73 m 2 ;Approx. 30~60mL / min / 1.73m 2;Approx. 40~70mL / min / 1.73m 2 ;Approx. 50~80mL / min / 1.73m 2 or about 60 to about 90 mL / min / 1.73 m 2 In some embodiments, the subject has a mean eGFR ≦60 mL / min / 1.73 m for at least about 3 months prior to the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 In certain embodiments, the subject has a mean eGFR ≦55 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦50 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦45 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦40 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦35 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦25 mL / min / 1.73 m for at least about 3 months. 2 In certain embodiments, the subject has a mean eGFR ≦20 mL / min / 1.73 m for at least about 3 months. 2 In certain of the above embodiments, the subject has a blood flow rate of about 30 mL / min / 1.73 m for at least 3 months prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 ~Approx. 60mL / min / 1.73m 2 For example, subjects have an average eGFR of about 30 mL / min / 1.73 m 2 ~Approx. 55mL / min / 1.73m 2 , about 30mL / min / 1.73m 2 ~About 50mL / min / 1.73m 2 , about 30mL / min / 1.73m 2 ~About 45mL / min / 1.73m 2 , or approximately 30 mL / min / 1.73 m2 ~Approx. 40mL / min / 1.73m 2 may have a mean eGFR of

[0283] In certain embodiments, the subject receives a blood glucose level of about 30 mL / min / 1.73 m for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist, or pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 ~About 45mL / min / 1.73m 2 In some embodiments, the subject has a mean eGFR of about 25 mL / min / 1.73 m, e.g., about ≦45, about ≦40, about ≦35, or about ≦30. In some embodiments, the subject has a mean eGFR of about 25 mL / min / 1.73 m for at least about 3 months prior to the first administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. 2 ~Approx. 75mL / min / 1.73m 2 For example, for at least about 3 months prior to the first administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, the patient has a mean eGFR of about 25 mL / min / 1.73 m 2 , about 30mL / min / 1.73m 2 , about 35mL / min / 1.73m 2 , approximately 40 mL / min / 1.73 m 2 , about 45mL / min / 1.73m 2 , about 50mL / min / 1.73m 2 , about 55mL / min / 1.73m 2 , about 60mL / min / 1.73m 2 , about 65mL / min / 1.73m 2 , about 70mL / min / 1.73m 2 , about 75mL / min / 1.73m 2 , or any value in between.

[0284] In some embodiments, the subject has an average HbA1c of about 4% to about 6% for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject may have an average HbA1c of about 4.2%, about 4.4%, about 4.6%, about 4.8%, about 5.0%, about 5.2%, about 5.4%, about 5.6%, about 5.8%, or about 6%, or any value therebetween.

[0285] In some embodiments, the subject has an average fasting blood glucose level of about 125 mg / dL or less for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject may have an average fasting blood glucose level of about 120 mg / dL, about 115 mg / dL, about 110 mg / dL, about 105 mg / dL, about 100 mg / dL, about 95 mg / dL, about 90 mg / dL, about 85 mg / dL, about 80 mg / dL, or about 75 mg / dL, or any value therebetween.

[0286] In some embodiments, the subject maintains potassium levels within the normal physiological range. In certain embodiments, the subject maintains potassium levels within the normal physiological range for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the subject maintains potassium levels within 3.5-5.2 mEq / L. For example, the subject maintains a mean potassium level of about 3.5 mEq / L, about 3.6 mEq / L, about 3.7 mEq / L, about 3.8 mEq / L, about 3.9, about mEq / L, about 4.0 mEq / L, about 4.1 mEq / L, about 4.2 mEq / L, about 4.3 mEq / L, about 4.4 mEq / L, about 4.5 mEq / L, about 4.6 mEq / L, about 4.7 mEq / L, about 4.8 mEq / L, about 4.9 mEq / L, about 5.0 mEq / L, about 5.1 mEq / L, or about 5.2 mEq / L, or any value therebetween.

[0287] In some embodiments, the subject maintains sodium levels within the normal physiological range. In certain embodiments, the subject maintains potassium levels within the normal physiological range for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the subject maintains sodium levels between 135 and 145 mEq / L. For example, the subject maintains an average sodium level of about 135 mEq / L, about 136 mEq / L, about 137 mEq / L, about 138 mEq / L, about 139 mEq / L, about 140 mEq / L, about 141 mEq / L, about 142 mEq / L, about 143 mEq / L, about 144 mEq / L, or about 145 mEq / L, or any value therebetween.

[0288] In some embodiments, the subject has ALT / AST levels during administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, that are about the same as the ALT / AST levels before the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject has ALT / AST levels during administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, that are within about 25%, about 20%, about 15%, about 10%, about 5%, or about 2.5%, or any value therebetween, of the levels before the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0289] In some embodiments, the subject has a bilirubin level during administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, that is about the same as the bilirubin level before the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject has a bilirubin level during administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, that is within about 25%, about 20%, about 15%, about 10%, about 5%, or about 2.5%, or any value therebetween, of the level before the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0290] In some embodiments, fluid retention in a subject is manageable with a diuretic (e.g., during treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, and / or prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof). For example, fluid retention can be a weight gain of less than about 3 kilograms (kg) over six weeks. In some embodiments, fluid retention is less than about 4 kg, about 3.5 kg, about 3 kg, about 2.5 kg, about 2 kg, about 1.5 kg, or about 1 kg, or any value therebetween, over six weeks.

[0291] In some embodiments, the subject undergoes surgery and / or other regimens prior to, substantially simultaneously with, or following administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, described herein. In some embodiments, the subject is administered other chemotherapeutic and / or biological agents prior to, substantially simultaneously with, or following administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, described herein.

[0292] In some embodiments, the subject has been administered one or more inhibitors of the renin-angiotensin system for at least about 60 weeks prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, in some embodiments, the subject has been administered one or more inhibitors of the renin-angiotensin system for at least about 12 weeks, about 24 weeks, about 48 weeks, or about 60 weeks, or any value therebetween, prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0293] In some embodiments, the subject has been administered a maximum tolerated stable dose of one or more renin-angiotensin system inhibitors. For example, the subject may be administered a maximum tolerated stable dose of one or more renin-angiotensin system inhibitors for at least about 12 weeks, about 14 weeks, about 16 weeks, about 18 weeks, about 20 weeks, about 25 weeks, about 30 weeks, about 35 weeks, about 40 weeks, about 45 weeks, or about 50 weeks, or any value therebetween, prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the one or more inhibitors of the renin-angiotensin system are selected from the group consisting of an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin II receptor blocker (ARB), a renin inhibitor, and an aldosterone antagonist. For example, the one or more inhibitors of the renin-angiotensin system can be an ACE inhibitor, an ARB, or a combination thereof, and the ACE inhibitor or ARB can be any of those described anywhere herein. For example, the ACE inhibitor can be selected from the group consisting of quinapril, fosinopril, perindopril, captopril, enalapril, enalaprilat, ramipril, cilazapril, delapril, fosenopril, zofenopril, indolapril, benazepril, lisinopril, spirapril, trandolapril, perindep, pentopril, moexipril, rescinnamine, and pivopril. For example, the ARB can be selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657.

[0294] In some embodiments, the subject is also receiving one or more additional agents. In some embodiments, the one or more additional agents are selected from the group consisting of a calcineurin inhibitor, a proteasome inhibitor, an aminoquinoline, a complement inhibitor, a B cell inhibitor, a cytotoxic agent, an mTOR inhibitor, and a steroid. In some embodiments, the dosage of the one or more additional agents is reduced after about 15 days to about 30 days of treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the one or more additional agents is an immunosuppressant.

[0295] In some embodiments, the subject is not currently receiving one or more additional medications, hi certain embodiments, the subject has not used one or more additional medications for two or more weeks within the six months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0296] In some embodiments, the one or more additional agents are selected from the group consisting of calcineurin inhibitors, proteasome inhibitors, aminoquinolines, complement inhibitors, B cell inhibitors, cytotoxic agents, mTOR inhibitors, and steroids.

[0297] In certain embodiments, the one or more additional agents are steroids. For example, the one or more additional agents can be selected from the group consisting of prednisone, dexamethasone, hydrocortisone, cyclosporine, and any combination of the foregoing.

[0298] In certain embodiments, the one or more additional agents are aminoquinolines. For example, the one or more additional agents can be hydroxychloroquine.

[0299] In some embodiments, the subject is receiving one or more additional medications during treatment with atrasentan. In certain embodiments, the dosage of the one or more additional medications is reduced after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (e.g., after 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 20 weeks, 30 weeks, 40 weeks, 50 weeks, 60 weeks, 70 weeks, 80 weeks, 90 weeks, 100 weeks, 110 weeks, 120 weeks, 130 weeks, 140 weeks, 150 weeks, 160 weeks, 170 weeks, 180 weeks, 190 weeks, or 200 weeks of treatment). In certain of these embodiments, the dosage of one or more additional agents is reduced after about 15 days to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain of the foregoing embodiments, the dosage of the additional agent is reduced by about 10% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 15% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 20% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 25% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 30% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 35% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 40% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 45% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 50% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 55% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 60% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 65% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 70% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 75% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 80% to about 100%. In certain embodiments, the dosage of the additional agent is reduced by about 85% to about 100%.In certain embodiments, the dosage of the additional agent is reduced by about 90% to about 100%. In certain of the above embodiments, the dosage of one or more additional agents is reduced after about 15 days to about 30 days (e.g., about 15 days, about 20 days, about 25 days, or about 30 days) of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. When the dosage of the additional agent is reduced by 100% as described herein, the subject no longer requires the additional agent.

[0300] In certain embodiments, the dosage of one or more steroids is reduced after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, e.g., after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the dosage of steroids is reduced by about 10% to about 100%, as described herein. In some embodiments, the dosage of prednisone, dexamethasone, hydrocortisone, cyclosporine, or a combination of any of the foregoing is reduced by about 10% to about 100% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0301] In certain embodiments, the dosage of one or more aminoquinolines is reduced after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, e.g., after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the dosage of the aminoquinoline is reduced by about 10% to about 100%, as described herein. In some embodiments, the dosage of hydroxychloroquine is reduced by about 10% to about 100% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0302] In some embodiments, the subject is concurrently administered one or more additional therapeutic agents. The one or more additional therapeutic agents are described herein. For example, the subject is concurrently administered an inhibitor of one or more components of the renin-angiotensin-aldosterone system. In certain embodiments, the subject is concurrently administered an SGLT-2 inhibitor, an ACE inhibitor, an ARB, a statin, a diuretic, a calcium channel blocker, a beta-blocker, an aldosterone antagonist, fish oil, hydroxychloroquine, or a combination of any of the foregoing. In certain of these embodiments, the subject is concurrently administered an SGLT-2 inhibitor. In certain of these embodiments, the subject is concurrently administered an ACE inhibitor, an ARB, or a combination thereof. In certain embodiments, the subject is concurrently administered one or more statins, such as atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, and pitavastatin. In certain embodiments, the subject is concurrently receiving one or more diuretics, such as hydrochlorothiazide, trichlormethiazide, hydroflumethiazide, quinethazone, metolazone, chlorothiazide, chlorthalidone, indapamide, methyclothiazide, bemethanide, torsemide, piretanide, ethacrynic acid, bumetanide, furosemide, triamterene, spironolactone, eplerenone, and amiloride. In certain embodiments, the subject is concurrently receiving an SGLT-2 inhibitor, such as canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin. In certain embodiments, the subject is concurrently receiving one or more ACE inhibitors, such as quinapril, fosenopril, perindopril, captopril, enalapril, enalaprilat, ramipril, cilazapril, delapril, fosinopril, zofenopril, indolapril, benazepril, lisinopril, spirapril, trandolapril, perindep, pentopril, moexipril, rescinnamine, and pivopril.In certain embodiments, the subject is concurrently administered an ARB, such as candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657. In certain embodiments, the subject is concurrently administered a diuretic and an ACE inhibitor or an ARB. In certain embodiments, the subject is concurrently administered a diuretic, an ACE inhibitor, and an ARB. In certain embodiments, the subject is concurrently administered a diuretic, an SGLT-2 inhibitor, and an ACE inhibitor or an ARB. In certain embodiments, the subject is concurrently administered a diuretic, an SGLT-2 inhibitor, an ACE inhibitor, and an ARB. In certain embodiments, the subject concurrently administered one or more additional therapeutic agents has not previously administered the one or more additional therapeutic agents. For example, a subject concurrently administered an SGLT-2 inhibitor has not previously administered an SGLT-2 inhibitor.

[0303] In some embodiments, the subject has previously, but not concurrently, been administered one or more additional therapeutic agents, such as those described herein. For example, the subject has previously, but not concurrently, been administered an SGLT-2 inhibitor, an ACE inhibitor, an ARB, a statin, a diuretic, a calcium channel blocker, a beta-blocker, an aldosterone antagonist, fish oil, hydroxychloroquine, or a combination of any of the foregoing, as described herein. In certain of these embodiments, the subject has previously, but not concurrently, been administered an SGLT-2 inhibitor.

[0304] In some embodiments, the subject has cellular glomerular crescents present in about ≦25% of glomeruli within 6 months prior to the initial administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. For example, the subject may have cellular glomerular crescents present in about 25%, about 20%, about 15%, about 10%, about 5%, or about 1% of glomeruli, or any value therebetween. In some embodiments, the subject has no cellular glomerular crescents present in glomeruli. In certain embodiments, the subject does not have clinical suspicion of rapidly progressive glomerulonephritis (RPGN).

[0305] In some embodiments, the subject has not undergone an organ transplant prior to the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0306] In some embodiments, the subject has a systolic blood pressure of less than about 160 mmHg before the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject may have a systolic blood pressure of less than about 155 mmHg, less than about 150 mmHg, less than about 145 mmHg, or less than about 140 mmHg. In some embodiments, the subject has a diastolic blood pressure of less than about 100 mmHg before the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject may have a diastolic blood pressure of less than about 100 mmHg, less than about 95 mmHg, or less than about 90 mmHg. In some embodiments, the subject has a systolic blood pressure of about 100 mmHg to about 130 mmHg and a diastolic blood pressure of about 70 mmHg to about 90 mmHg.

[0307] In some embodiments, the subject has not been diagnosed with heart failure prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not been previously hospitalized for a condition associated with fluid overload prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. Non-limiting examples of conditions include uncontrolled peripheral edema, pleural effusion, or ascites. In some embodiments, the subject has not been diagnosed with clinically significant liver disease prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject's transaminase or bilirubin levels are less than or equal to two times the upper limit of normal prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the subject's ALT level is less than about 110 U / L (e.g., less than about 100 U / L, less than about 90 U / L, less than about 80 U / L, less than about 70 U / L, less than about 60 U / L, less than about 50 U / L, or less than about 40 U / L, or any value therebetween). As another example, the subject's AST level is less than 100 U / L (e.g., less than 90 U / L, less than about 80 U / L, less than about 70 U / L, less than about 60 U / L, less than about 50 U / L, or less than about 40 U / L, or any value therebetween). As yet another example, the subject's bilirubin level is less than about 2.5 mg / dL (e.g., less than about 2 mg / dL, less than about 1.5 mg / dL, less than about 1.4 mg / dL, less than about 1.3 mg / dL, less than about 1.2 mg / dL, less than about 1.1 mg / dL, less than about 1.0 mg / dL, or less than about 0.9 mg / dL, or any value therebetween).

[0308] In some embodiments, the subject has a hemoglobin level of greater than about 9 g / dL (e.g., greater than about 10 g / dL, about 11 g / dL, about 12 g / dL, or about 13 g / dL, or any value therebetween) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not received a blood transfusion for anemia for at least about 3 months (e.g., at least about 4 months, about 5 months, about 6 months, or about 1 year) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not been diagnosed with cancer for at least 5 years prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not been diagnosed with cancer (e.g., lung cancer or prostate cancer) for at least five years prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not been diagnosed with cancer (unless the cancer is a non-melanoma skin cancer that does not require current treatment) for at least five years prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject does not have cancer (unless the cancer is a non-melanoma skin cancer that does not require current treatment) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject does not have cancer prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (unless the cancer is a non-melanoma skin cancer that does not require current treatment).In some embodiments, the subject has not received treatment for cancer (unless the cancer is a non-melanoma skin cancer that does not require current treatment) for at least 5 years prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0309] In some embodiments, the subject has been determined to have a controlled serum glucose level. In certain embodiments, the subject has been determined to have a controlled serum glucose level. For example, the subject has been determined to have a fasting serum glucose level of less than about 130 mg / dL, about 125 mg / dL, about 120 mg / dL, about 115 mg / dL, about 110 mg / dL, about 105 mg / dL, about 100 mg / dL, about 95 mg / dL, about 90 mg / dL, about 85 mg / dL, about 80 mg / dL, or about 75 mg / dL, or any value therebetween.

[0310] In some embodiments, the subject has not been previously diagnosed with a chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic kidney disease, hypertensive kidney disease, or a primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject has not been previously diagnosed with diabetic kidney disease. In certain embodiments, the subject has not been previously diagnosed with hypertensive kidney disease. In certain embodiments, the subject has not been diagnosed with a primary glomerulopathy determined to be unrelated to IgA nephropathy.

[0311] In some embodiments, the subject does not have a chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic kidney disease, hypertensive kidney disease, or a primary glomerulopathy determined to be unassociated with IgA nephropathy. In certain embodiments, the subject does not have diabetic kidney disease. In certain embodiments, the subject does not have hypertensive kidney disease. In certain embodiments, the subject does not have a primary glomerulopathy determined to be unassociated with IgA nephropathy.

[0312] In some embodiments, the subject does not suffer from a chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic kidney disease, hypertensive kidney disease, or a primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject does not suffer from diabetic kidney disease. In certain embodiments, the subject does not suffer from hypertensive kidney disease. In certain embodiments, the subject does not suffer from a primary glomerulopathy determined to be unrelated to IgA nephropathy.

[0313] In some embodiments, the subject is not being treated for a chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic kidney disease, hypertensive kidney disease, or a primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject is not being treated for diabetic kidney disease. In certain embodiments, the subject is not being treated for hypertensive kidney disease. In certain embodiments, the subject is not being treated for a primary glomerulopathy determined to be unrelated to IgA nephropathy.

[0314] Treatment results In some embodiments of the methods, uses, or products for use herein, nephritis is reduced following treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the subject's nephritis is reduced by at least about 10% after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In some embodiments, the subject's nephritis is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0315] In some embodiments, renal fibrosis is reduced following treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject's renal fibrosis is reduced by at least about 10% after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's renal fibrosis is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0316] In some embodiments, the subject's renal fibrosis is reduced to less than about 50% of the cortical area after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof (e.g., 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's renal fibrosis is reduced to less than about 40% of the cortical area. For example, in some embodiments, the subject's renal fibrosis is reduced to less than about 35%, about 30%, about 25%, about 20%, about 15%, or about 10% of the cortical area, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0317] In some embodiments, the incidence of hematuria in a subject is reduced following treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the number of urinary red blood cells per high-power (microscopic) field (rbc / hpf) in a subject is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks after treatment). In certain embodiments, the subject's urinary rbc / hpf is reduced by at least about 20%. For example, in some embodiments, the subject's urinary RBC / HPF is reduced by at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0318] In some embodiments, the subject's rate of decline in eGFR is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof (e.g., over 1 week, 2 weeks, 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the subject's rate of decline in eGFR is reduced by at least about 20%. For example, in some embodiments, the subject's eGFR declines by at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, for about 15 days to about 30 days. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, for about 6 months to about 1 year.

[0319] In some embodiments, the subject's rate of decline in eGFR decreases to less than about 10 mL / min per year after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween after treatment). In some embodiments, the subject's rate of decline in eGFR decreases to less than about 9 mL / min per year. For example, in some embodiments, the subject's eGFR declines by less than about 8 mL / min per year, about 7 mL / min per year, about 6 mL / min per year, about 5 mL / min per year, about 4 mL / min per year, about 3 mL / min per year, about 2 mL / min per year, or about 1 mL / min per year, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 to about 30 days. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 6 months to about 1 year.

[0320] In some embodiments, the subject's risk of developing ESRD is reduced by about 20% to about 99% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). For example, a subject's risk of developing ESRD may be reduced by about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 99%, or any value therebetween. In certain of the foregoing embodiments, the subject has been treated for about 90 to about 180 days. In particular embodiments, the subject's risk of developing ESRD is reduced by about 20% to about 99% after about 90 to about 180 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 6 months to about 1 year.

[0321] In some embodiments, the methods include diagnosing IgA nephropathy in a subject and determining whether the subject's eGFR is about 15 mL / min / 1.73 m 2 In certain embodiments, the method increases the time between a diagnosis of IgA nephropathy in a subject and the time the subject's eGFR drops below 15 mL / min / 1.73 m. 2 For example, in some embodiments, the method increases the time between a diagnosis of IgA nephropathy in a subject and the time the subject's eGFR drops to less than about 15 mL / min / 1.73 m by at least about 10%. 2The time between the time the concentration drops below 100%, is increased by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 95%, about 100%, about 150%, about 200%, about 250%, about 300%, about 350%, about 400%, about 450%, or about 500%, or any value therebetween.

[0322] In some embodiments, the methods include diagnosing IgA nephropathy in a subject and determining whether the subject's eGFR is 15 mL / min / 1.73 m 2 For example, the method may increase the time between when the subject's eGFR drops below 15 mL / min / 1.73 m for at least about 1 year. 2 The time for the blood glucose level to drop below 100 ppm may be delayed by at least about 1.5 years, about 2 years, about 2.5 years, about 3 years, about 3.5 years, about 4 years, about 4.5 years, about 5 years, about 5.5 years, about 6 years, about 6.5 years, about 7 years, about 7.5 years, about 8 years, about 8.5 years, about 9 years, about 9.5 years, about 10 years, about 11 years, about 12 years, about 13 years, about 15 years, about 15 years, about 16 years, about 17 years, about 18 years, about 19 years, or about 20 years, or any value therebetween.

[0323] In some embodiments, the method reduces the mean rate of decline in eGFR by about 0.75 mL / min / year to about 6 mL / min / year for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. For example, the method reduces the mean rate of decline in eGFR by about 0.75 mL / min / year, about 1 mL / min / year, about 1.5 mL / min / year, about 2 mL / min / year, about 2.5 mL / min / year, about 3 mL / min / year, about 3.5 mL / min / year, about 4 mL / min / year, about 4.5 mL / min / year, about 5 mL / min / year, about 5.5 mL / min / year, or about 6 mL / min / year. In some embodiments, the method reduces the mean rate of decline in eGFR by about 4 mL / min / year to about 5 mL / min / year for at least about 3 months prior to the initial administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the method reduces the mean rate of decline in eGFR by about 3 mL / min / year to about 6 mL / min / year for at least about 3 months prior to the first administration of the endothelin receptor antagonist, or pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the method reduces the mean rate of decline in eGFR by about 4 mL / min / year to about 5 mL / min / year for at least about 3 months prior to the first administration of the endothelin receptor antagonist, or pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the decline in eGFR in mL / min / year is 1.73 m / year or less. 2 Refers to the unit of measure.

[0324] In some embodiments, the method reduces the mean rate of decline in eGFR by about 15% to about 30% after about 6 to about 24 months of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the mean rate of decline in eGFR can be reduced by about 15% after about 6, 9, 12, 15, 18, 21, or 24 months of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the mean rate of decline in eGFR can be reduced by about 20% after about 6, 9, 12, 15, 18, 21, or 24 months of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, after about 6, 9, 12, 15, 18, 21, or 24 months of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, the average percentage decline in eGFR may be reduced by about 25%. In some embodiments, after about 6, 9, 12, 15, 18, 21, or 24 months of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, the average percentage decline in eGFR may be reduced by about 30%.

[0325] In another aspect, provided herein is a method for reducing proteinuria, the method comprising administering to a subject in need thereof an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0326] In some embodiments, the amount of protein (e.g., albumin) in the subject's urine is reduced by at least about 10% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In some embodiments, the amount of protein in the subject's urine is reduced by at least about 15%. For example, in some embodiments, the amount of protein in the subject's urine is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0327] In certain embodiments, the amount of protein (e.g., albumin) in the subject's urine is reduced by about 20% to about 80% after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 25% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 30% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 35% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 40% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 45% to about 80%. In certain of these embodiments, the amount of protein in the subject's urine is reduced by about 50% to about 80%.

[0328] In some embodiments, the amount of protein (e.g., albumin) in the subject's urine is reduced by about 100 mg / dL to about 3,000 mg / dL after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 2,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 2,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 1,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 1,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 400 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 300 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 100 mg / dL to about 200 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 2,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 2,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 1,500 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 1,000 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 900 mg / dL.In certain embodiments, the amount of protein in the subject's urine is reduced by about 500 mg / dL to about 800 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 600 mg / dL to about 900 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 700 mg / dL to about 900 mg / dL. In certain embodiments, the amount of protein in the subject's urine is reduced by about 1,000 mg / dL to about 2,000 mg / dL. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0329] In certain embodiments, the amount of protein (e.g., albumin) in a subject's urine is reduced by about 100 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in a subject's urine is reduced by about 200 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in a subject's urine is reduced by about 300 mg / dL to about 500 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0330] In certain embodiments, the amount of protein (e.g., albumin) in a subject's urine is reduced by about 500 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in a subject's urine is reduced by about 600 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof. In certain embodiments, the amount of protein in a subject's urine is reduced by about 700 mg / dL to about 900 mg / dL after about 15 to about 30 days of treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0331] In some embodiments, the subject has a reduction in urinary protein (e.g., albumin) levels of less than about 1.0 gram / day after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks after treatment). In some embodiments, the subject has a reduction in urinary protein levels of less than about 0.9 gram / day. For example, in some embodiments, the subject has a reduction in urinary protein levels of less than about 0.8 grams / day, about 0.7 grams / day, about 0.6 grams / day, 0.5 grams / day, about 0.4 grams / day, about 0.3 grams / day, or about 0.2 grams / day, or any value therebetween. In certain of the above embodiments, the subject has been treated with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.

[0332] In some embodiments, the subject is about 15 to about 40 years old. In some embodiments, the subject is about 15 to about 25 years old, about 20 to about 30 years old, about 25 to about 35 years old, about 30 to about 40 years old, or any age therebetween. In some embodiments, the subject is about 20 to about 30 years old, or any age therebetween. In some embodiments, the subject is about 20 years old, about 21 years old, about 22 years old, about 23 years old, about 24 years old, about 25 years old, about 26 years old, about 27 years old, about 28 years old, about 29 years old, or about 30 years old.

[0333] In some embodiments, the patient's level of fatigue is reduced following treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, fatigue is reduced by about 5% to about 80% after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment). In certain embodiments, fatigue is reduced by about 10% to about 75%. In certain embodiments, fatigue is reduced by about 10% to about 70%. In certain embodiments, fatigue is reduced by about 10% to about 65%. In certain embodiments, fatigue is reduced by about 10% to about 60%. In certain embodiments, fatigue is reduced by about 10% to about 55%. In certain embodiments, fatigue is reduced by about 10% to about 50%. In certain embodiments, fatigue is reduced by about 10% to about 45%. In certain embodiments, fatigue is reduced by about 10% to about 40%. In certain embodiments, fatigue is reduced by about 10% to about 35%. In certain embodiments, fatigue is reduced by about 10% to about 30%. In certain embodiments, fatigue is reduced by about 10% to about 25%. In certain embodiments, fatigue is reduced by about 10% to about 20%. In certain embodiments, fatigue is reduced by about 10% to about 15%. In certain of the above embodiments, the subject has been treated with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for about 15 days to about 30 days.In certain embodiments, a reduction in fatigue comprises a decrease in score on one or more of the Fatigue Severity Scale, the Chalder Fatigue Scale, the FACIT Fatigue Scale, the Brief Fatigue Inventory, the FACT-F subscale, the Global Vigor and Affect, the May and Kline Adjunctive Checklist, the Pearson-Byars Fatigue Checklist, the Rhoten Fatigue Scale, the Schedule for Fatigue and Anergy, or the Personal Fitness Checklist.

[0334] In some embodiments, a method is provided for inhibiting mesangial cell activation in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0335] In some embodiments, a method is provided for inhibiting PDGF signaling activity (e.g., reducing the expression and / or activity of one or more of PIK3R1, PDGFRA, NFKBIA, PIK3CG, PLA2G4A, TIAM1, PDGFB, NFKB1, and MAP3K1) in mesangial cells in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0336] In some embodiments, a method of inhibiting mesangial cell activation is provided, comprising contacting mesangial cells with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof.

[0337] In some embodiments, mesangial activation is induced by IgA immune complexes. In some embodiments, mesangial activation is associated with the presence of IgA immune complexes. The presence and / or amount of IgA immune complexes can be detected by a variety of methods. For example, the complexes can be detected in serum or urine, and can also be detected in kidney biopsy samples.

[0338] In some embodiments, inhibiting mesangial cell activation comprises reducing the expression and / or activity of one or more biomarkers indicative of mesangial cell proliferation. In some embodiments, inhibiting mesangial cell activation comprises reducing mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing the expression and / or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing the expression and / or activity of IL-6. In some embodiments, the expression and / or activity of one or more biomarkers indicative of mesangial cell inflammation is reduced by about 25% to about 99% following treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., over about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, following treatment). In some embodiments, the expression and / or activity of one or more biomarkers indicative of mesangial cell inflammation is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween. For example, in some such embodiments, the one or more biomarkers can be IL-6.

[0339] In some embodiments, inhibiting mesangial cell activation comprises reducing mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing IL-6 signaling (e.g., reducing the expression and / or activity of one or more proteins involved in the IL-6 signaling pathway, e.g., reducing the expression and / or activity of one or more of Cntfr, Il1b, Csf1, Il2ra, Map3k8, and Il1r1). In some embodiments, reducing mesangial cell inflammation comprises reducing the expression and / or activity of one or more (e.g., 1, 2, 3, 4, or 5) of the following: Cntfr, Il1b, Csf1, Il2ra, Map3k8, Il1r1.

[0340] In some embodiments, inhibiting mesangial cell activation comprises reducing a pro-fibrotic response in mesangial cells. In some embodiments, reducing a pro-fibrotic response in mesangial cells comprises reducing the expression and / or activity of one or more of NF-κB, TGF, PDGF, CTGF, MMP, TIMPS, or other biomarkers indicative of mesangial cell fibrosis. In some embodiments, the expression and / or activity of one or more of NF-κB, TGF, PDGF, CTGF, MMP, and TIMPS is decreased after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof (e.g., at about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks after treatment). or about 200 weeks, or any value therebetween), the expression and / or activity is reduced by about 25% to about 99% compared to the expression and / or activity prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the expression and / or activity of one or more of NF-κB, TGF, PDGF, CTGF, MMPs, and TIMPS is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

[0341] In some embodiments, inhibiting mesangial cell activation comprises reducing a profibrotic response in mesangial cells. In some embodiments, reducing a profibrotic response comprises reducing NF-κB signaling. In some embodiments, reducing a profibrotic response comprises reducing Pfkfb3, Nr4a1, Gem, Fosl2, Klf4, F3, Nfkbia, Ifit2, Nr4a2, Klf2, Jag1, Dnajb4, Il1b, Spsb1, Btg2, Atf3, Csf1, Trib1, Zbtb10, Btg1, Rhob, Nfat5, Edn1, Rel, Nr4a3, Nfkb1, Serpine1, Ccl20, Per1, Cxcl 2, Map3k8, Traf1, and / or increasing the expression and / or activity of one or more (e.g., 1, 2, 3, 4, or 5) of Ehd1, Snn, Tnfaip8, Ackr3, Id2, Ccn1, Efna1, Ccnd1, Cdkn1a, Pnrc1 (where the component inhibits NF-κB signaling).

[0342] In some embodiments, reducing a profibrotic response comprises reducing PDGF signaling, hi some embodiments, reducing a profibrotic response comprises reducing the expression and / or activity of one or more (e.g., 1, 2, 3, 4, or 5) of Pik3r1, Pdgfra, Nfkbia, Pik3cg, Pla2g4a, Tiam1, Pdgfb, Nfkb1, and / or increasing the expression and / or activity of one or more (e.g., 1, 2, 3, 4, or 5) of Hras (if the component inhibits PDGF signaling).

[0343] In some embodiments, the expression and / or activity of NF-κB and / or PDGF expression and / or activity is measured after treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks after treatment). In some embodiments, the expression and / or activity of NF-κB and / or PDGF is reduced by about 25% to about 99%, compared to the expression and / or activity before administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, over a period of about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween. In some embodiments, the expression and / or activity of NF-κB and / or PDGF is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

[0344] In some embodiments, reducing a pro-fibrotic response in mesangial cells comprises reducing matrix secretion by mesangial cells, hi some embodiments, reducing matrix secretion by mesangial cells comprises reducing the expression and / or activity of one or more of the factors that contribute to excessive matrix secretion by mesangial cells.

[0345] In some embodiments, methods are provided for reducing activation of mesangial cells in contact with IgA immune complexes, comprising contacting mesangial cells with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof. In some embodiments, reducing mesangial cell activation comprises reducing the expression and / or activity of one or more biomarkers indicative of mesangial cell proliferation.

[0346] In some embodiments, reducing mesangial cell activation comprises reducing mesangial cell inflammation, hi some embodiments, reducing mesangial cell inflammation comprises reducing the expression and / or activity of one or more of IL-6, MCP1, or other biomarkers indicative of mesangial cell inflammation.

[0347] In some embodiments, reducing mesangial cell activation comprises reducing a profibrotic response in mesangial cells, hi some embodiments, reducing a profibrotic response in mesangial cells comprises reducing the expression and / or activity of one or more of TGF, PDGF, CTGF, MMPs, TIMPS, or other biomarkers indicative of mesangial cell fibrosis.

[0348] In some embodiments, reducing a pro-fibrotic response in mesangial cells comprises reducing matrix secretion by mesangial cells, hi some embodiments, reducing matrix secretion by mesangial cells comprises reducing the expression and / or activity of one or more biomarkers indicative of excessive matrix secretion by mesangial cells.

[0349] In some embodiments, reducing mesangial cell activation comprises reducing unwanted mesangial cell migration. In some embodiments, the reduction in unwanted mesangial cell migration occurs about 15 to about 30 days after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the reduction in unwanted mesangial cell migration occurs about 3 to about 6 months after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0350] In some embodiments, reducing mesangial cell activation comprises reducing unwanted mesangial cell proliferation. In some embodiments, the reduction in unwanted mesangial cell proliferation occurs about 15 to about 30 days after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the reduction in unwanted mesangial cell proliferation occurs about 3 to about 6 months after treatment with the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0351] In some embodiments, unwanted mesangial cell proliferation is reduced by about 25% to about 99% following treatment with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof (e.g., about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, following treatment). In some embodiments, unwanted mesangial cell proliferation is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

[0352] In some embodiments, mesangial cell activation can be assessed by one or more of serum analysis, urinalysis, and microscopic examination (eg, light microscopy and / or immunofluorescence microscopy) of a kidney biopsy sample.

[0353] In some embodiments, the contacting occurs in vitro. In some embodiments, the contacting occurs in vivo.

[0354] In some embodiments, a method for treating IgA nephropathy in a subject in need thereof is provided, the method comprising: a) determining that the subject has an elevated serum Gd-IgA1 level; and b) administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0355] In some embodiments, a method of treating IgA nephropathy in a subject in need thereof is provided, the method comprising: a) determining that the subject has elevated levels of mesangial activation; and b) administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0356] In some embodiments, determining a high level of mesangial activation comprises obtaining a sample from the subject and assessing the level of mesangial activation in the sample. In some embodiments, the sample is a kidney biopsy sample. In some embodiments, the sample is selected from a blood sample, a urine sample, a kidney biopsy sample, or a combination of two or three of the foregoing.

[0357] In some embodiments, the sample exhibits elevated levels of one or more of the following: matrix secretion by mesangial cells, IgA immune complex deposition, mesangial cell proliferation, and intraductal cell proliferation, hi some embodiments, the sample exhibits elevated levels of IgA immune complex deposition.

[0358] In some embodiments, the subject has been determined to have proteinuria of at least about 1 g / day in at least two of three consecutive measurements over the one year period prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, e.g., about 1 g / day, about 1.2 g / day, about 1.4 g / day, about 1.6 g / day, about 1.8 g / day, or at least about 2 g / day.

[0359] In some embodiments, the subject has been administered a maximum tolerated stable dose of a RAS inhibitor for at least 12 weeks prior to administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the subject is concurrently administered a maximum tolerated stable dose of a RAS inhibitor, an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the RAS inhibitor is an angiotensin-converting enzyme inhibitor. In some embodiments, the RAS inhibitor is an angiotensin receptor blocker (ARB).

[0360] In some embodiments, the subject is determined to have hematuria prior to administering the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the hematuria is microhematuria. In some embodiments, the hematuria is gross hematuria.

[0361] In some embodiments, the subject receives an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, at a blood flow rate of at least 30 mL / min / 1.73 m 2 In some embodiments, the subject has been determined to have an eGFR of about 30 mL / min / 1.73 m prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 ~Approx. 60mL / min / 1.73m 2 It has been determined that the patient has an eGFR of .

[0362] In some embodiments, a method of treating IgA nephropathy in a subject in need thereof is provided, the method comprising: a) determining that the subject has elevated levels of IgA immune complexes in the kidney; and b) administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof.

[0363] In some embodiments, determining elevated levels of IgA immune complexes in the kidney comprises obtaining a sample from the subject and assessing the level of IgA immune complexes in the sample. In some embodiments, the sample is a kidney biopsy sample. In some embodiments, the sample is selected from a blood sample, a urine sample, a kidney biopsy sample, or a combination of two or three of the foregoing. In some embodiments, the IgA immune complexes are deposited in the mesangium.

[0364] In some embodiments, the level of IgA immune complexes can be assessed by one or more of serum analysis, urinalysis, and microscopic examination (e.g., light microscopy and / or immunofluorescence microscopy) of a kidney biopsy sample.

[0365] In some embodiments, the sample exhibits elevated levels of one or more of the following: matrix secretion by mesangial cells, IgA immune complex deposition in the mesangium, mesangial cell activation, mesangial cell proliferation, and intraductal cell proliferation.

[0366] In some embodiments, the subject has been determined to have proteinuria of at least about 1 g / day in at least two of three consecutive measurements over the one year period prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, e.g., about 1 g / day, about 1.2 g / day, about 1.4 g / day, about 1.6 g / day, about 1.8 g / day, or at least about 2 g / day.

[0367] In some embodiments, the subject has been administered a maximum tolerated stable dose of a RAS inhibitor for at least 12 weeks prior to administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the subject is concurrently administered a maximum tolerated stable dose of a RAS inhibitor, an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof. In some embodiments, the RAS inhibitor is an angiotensin-converting enzyme inhibitor. In some embodiments, the RAS inhibitor is an angiotensin receptor blocker (ARB).

[0368] In some embodiments, the subject is determined to have hematuria prior to administering the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the hematuria is microhematuria. In some embodiments, the hematuria is gross hematuria.

[0369] In some embodiments, the subject receives an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, at a blood flow rate of at least 30 mL / min / 1.73 m 2 In some embodiments, the subject has been determined to have an eGFR of about 30 mL / min / 1.73 m prior to administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. 2 ~Approx. 60mL / min / 1.73m 2 It has been determined that the patient has an eGFR of .

[0370] In some embodiments, the methods include determining the expression and / or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, and NF-kB in the subject. In some embodiments, the expression and / or activity is determined prior to administering the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, the expression and / or activity is determined after administering the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof.

[0371] In some embodiments, determining the expression and / or activity is performed prior to administering the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof. In some embodiments, determining expression and / or activity is performed after administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, for example, about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween, after treatment.

[0372] In some embodiments, the subject is diagnosed with ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, NF-kB, PKC, PI3K, Src, Ras, ERK1 / 2, Rho, Rac, Akt, mTOR, NAPDH oxidase, MAPK, cPLA2, TNF-α, IL-1, CAM, COX-2, iNOS, JAK, STAT3, PI3K, Akt / PKB, IKKs, IkBs, NF-kB, MAPK, Ras, Raf, MEK, ERK, MCP1, Cntfr, Il1b, Csf1, Il2ra, Map3k8 , Il1r1, Pfkfb3, Nr4a1, Gem, Fosl2, Klf4, F3, Nfkbia, Ifit2, Nr4a2, Klf2, Jag1, Dnajb4, Il1b, Spsb1, Btg2, Atf3, Csf1, Trib1, Zbtb10, Btg1, Rhob, Nfat5, Edn1, Rel, Nr4a3, Nfkb1, Serpine1, Ccl20, Per1, Cxcl2, Map3k8, Traf1, Pik3r1, Pdgfra, Nfkbia, Pik3cg, Pla2g4a, Tiam1, and Pdgfb. In some embodiments, the subject has been determined to have elevated expression and / or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, NF-kB, PKC, PI3K, Src, Ras, ERK1 / 2, Rho, Rac, Akt, mTOR, NAPDH oxidase, MAPK, cPLA2, TNF-α, IL-1, CAM, COX-2, iNOS, JAK, STAT3, PI3K, Akt / PKB, IKKs, IkBs, NF-kB, MAPK, Ras, Raf, MEK, ERK, and MCP1.In some embodiments, the subject has been determined to have high expression and / or activity of one or more of Cntfr, Il1b, Csf1, Il2ra, Map3k8, Il1r1, Pfkfb3, Nr4a1, Gem, Fosl2, Klf4, F3, Nfkbia, Ifit2, Nr4a2, Klf2, Jag1, Dnajb4, Il1b, Spsb1, Btg2, Atf3, Csf1, Trib1, Zbtb10, Btg1, Rhob, Nfat5, Edn1, Rel, Nr4a3, Nfkb1, Serpine1, Ccl20, Per1, Cxcl2, Map3k8, Traf1, Pik3r1, Pdgfra, Nfkbia, Pik3cg, Pla2g4a, Tiam1, and Pdgfb. In some embodiments, the subject has been determined to have elevated expression and / or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, and NF-kB, hi some embodiments, the subject has been determined to have elevated expression and / or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, and SLC6A19.

[0373] In some embodiments, a method of treating IgA nephropathy in a subject is provided, the method including: (a) the subject receiving one of the following antibodies to ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, NF-kB, PKC, PI3K, Src, Ras, ERK1 / 2, Rho, Rac, Akt, mTOR, NAPDH oxidase, MAPK, cPLA2, TNF-α, IL-1, CAM, COX-2, iNOS, JAK, STAT3, PI3K, Akt / PKB, IKKs, IkBs, NF-kB, MAPK, Ras, Raf, MEK, ERK, MCP1, Cntfr, Il1b, Csf1, Il2ra, Map3k8, Il1r1, Pfkfb3, Nr4a1, G the expression and / or activity of one or more of endothelin receptor antagonists, Fosl2, Klf4, F3, Nfkbia, Ifit2, Nr4a2, Klf2, Jag1, Dnajb4, Il1b, Spsb1, Btg2, Atf3, Csf1, Trib1, Zbtb10, Btg1, Rhob, Nfat5, Edn1, Rel, Nr4a3, Nfkb1, Serpine1, Ccl20, Per1, Cxcl2, Map3k8, Traf1, Pik3r1, Pdgfra, Nfkbia, Pik3cg, Pla2g4a, Tiam1, and Pdgfb; and (b) administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof.

[0374] In some embodiments, ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6A19, IL-6, NF-kB, PKC, PI3K, Src, Ras, ERK1 / 2, Rho, Rac, Akt, mTOR, NAPDH oxidase, MAPK, cPLA2, TNF-α, IL-1 , CAM, COX-2, iNOS, JAK, STAT3, PI3K, Akt / PKB, IKKs, IkBs, NF-kB, MAPK, Ras, Raf, MEK, ERK, MCP 1, Cntfr, Il1b, Csf1, Il2ra, Map3k8, Il1r1, Pfkfb3, Nr4a1, Gem, Fosl2, Klf4, F3, Nfkbia, Ifit 2, Nr4a2, Klf2, Jag1, Dnajb4, Il1b, Spsb1, Btg2, Atf3, Csf1, Trib1, Zbtb10, Btg1, Rhob, Nfat5, Edn1, Rel, Nr4a3, Nfkb1, Serpine1, Ccl20, Per1, Cxcl2, Map3k8, Traf1, Pik3r1, Pdgfra, Nfkbia, Pik3cg, Pla2g4a, Tiam1, and Pdgfb, the method comprising administering to the subject an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof.

[0375] In any of the embodiments described herein, various combinations of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, that produce an effect are contemplated. In some embodiments, the effect, e.g., any of the beneficial or desired results described herein, when co-administered, is greater than the sum of the effects observed when the same amounts of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or an antigen-binding fragment thereof, are administered as monotherapy. In some embodiments, co-administration of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or an antigen-binding fragment thereof, produces an effect, e.g., a therapeutic effect, using lower doses of either or both of the compounds as monotherapy. For example, producing a therapeutic effect using lower doses of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or an antigen-binding fragment thereof, compared to the amounts used in monotherapy. For example, in some embodiments, the dose of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, administered in combination with an APRIL binding antibody, or an antigen-binding fragment thereof, may be about 50% to about 90% of the dose of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, administered as a monotherapy to produce the same therapeutic effect, e.g., any beneficial or desired result, including those described herein. In some embodiments, the dose of an APRIL binding antibody, or an antigen-binding fragment thereof, administered in combination with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, may be about 50% to about 90% of the dose of the APRIL binding antibody, or an antigen-binding fragment thereof, administered as a monotherapy to produce the same therapeutic effect, e.g., any beneficial or desired result, including those described herein. For example, treatment of IgA nephropathy, reduction in nephritis and / or fibrosis, reduction in hematuria, reduction in proteinuria, stabilization of eGFR, reduction in the number of IgA nephropathy-associated disease flares, delay in the onset of ESRD, reduction in fatigue, and reduction in mesangial cell activation.

[0376] C. Atrasentan Atrasentan, also known as (2R,3R,4S)-4-(1,3-benzodioxol-5-yl)-1-[2-(dibutylamino)-2-oxoethyl]-2-(4-methoxyphenyl)pyrrolidine-3-carboxylic acid, ABT-627, A-147627, or A-127722, is a small molecule of the following chemical structure: [ka]

[0377] Atrasaentan and methods for its preparation are described in US Pat. No. 7,208,517 and WO 1997 / 030045 (see, eg, Example 501).

[0378] In some embodiments, atrasentan is administered as the free base. In some other embodiments, atrasentan is administered as a pharmaceutically acceptable salt, as described elsewhere herein.

[0379] Atrasentan is an ET B than ET A Approximately 1,860 times more selective than ET A As used herein, "ET A " is an abbreviation for endothelin receptor A; "ET B " is an abbreviation for endothelin receptor B. See, e.g., Ann Rheum Dis., 66(11), pp. 1467-1472 (2007); Eur. Resp. J., 37, pp. 475-476 (2011); Plos One, 9, e87548 (2014); J. Clin. Oncol., 10, 31(14), pp. 1740-7 (2013); Pharmacol. Rev., 68(2), pp. 357-418 (2016); and Nephrol. Dial. Transplant., 29, pp. i69-i73 (2014).

[0380] salt In some embodiments, atrasentan is in the form of a pharmaceutically acceptable salt. As used herein, the phrase "pharmaceutically acceptable salt" refers to a pharmaceutically acceptable organic or inorganic salt of a compound of the present disclosure (e.g., atrasentan). Exemplary salts include acid addition salts formed by reacting atrasentan with an acid (e.g., an organic acid or an inorganic acid). Non-limiting examples include: sulfate, citrate, acetate, oxalate, chloride, bromide, iodide, nitrate, bisulfate, phosphate, acid phosphate, isonicotinate, lactate, salicylate, acid citrate, tartrate, oleate, tannate, pantothenate, bitartrate, ascorbate, succinate, maleate, mandelate (e.g., (S)-mandelate or (R)-mandelate), gentisinate, fumarate, gluconate, glucuronate, saccharinate, formate, benzoate, glutamate, methanesulfonate "mesylate", ethanesulfonate, benzenesulfonate, and p-toluenesulfonate, pamoate (i.e., 4,4'-methylene-bs-(2-hydroxy-3-naphthoate)) salt. Exemplary salts also include base addition salts formed by the reaction of atrasentan with a base. Non-limiting examples include alkali metal (e.g., sodium and potassium) salts, alkaline earth metal (e.g., magnesium) salts, and ammonium salts. Pharmaceutically acceptable salts may involve the inclusion of another molecule, such as an acetate ion, a succinate ion, or other counterion. A counterion can be any organic or inorganic moiety that stabilizes the charge on the parent compound. Furthermore, a pharmaceutically acceptable salt can have more than one charged atom in its structure. Multiple counterions can be present when multiple charged atoms are part of the pharmaceutically acceptable salt. Thus, a pharmaceutically acceptable salt can have one or more charged atoms and / or one or more counterions. When referring to atrasentan, the term "salt" is understood to be a salt of atrasentan, which can be present alone or in a mixture with free atrasentan.

[0381] In some embodiments, atrasentan is in the form of a hydrochloride salt. In some embodiments, the atrasentan hydrochloride salt has a molar ratio of atrasentan to HCl of 1:1.

[0382] In some embodiments, atrasentan is in the form of a mandelate salt. In certain embodiments, atrasentan is in the form of (S)-mandelate salt. In certain embodiments, atrasentan is in the form of (R)-mandelate salt. In certain embodiments, in the atrasentan mandelate salt, atrasentan and the mandelate salt have a molar ratio of 1:1. In certain embodiments, in the atrasentan mandelate salt, atrasentan and the mandelate salt have a molar ratio of 2:1. Atrasentan mandelate salt and methods for its preparation are further described in U.S. Patent Nos. 8,962,675 and 9,637,476.

[0383] In some embodiments, atrasentan is in the form of a hemisulfate salt. Hemisulfate salts and methods for their preparation are further described in U.S. Patent Nos. 8,962,675 and 9,637,476.

[0384] In some embodiments, atrasentan or a pharmaceutically acceptable salt thereof is in the form of an anhydrate. In certain embodiments, atrasentan or a pharmaceutically acceptable salt thereof is in the form of a hydrate. In certain embodiments, atrasentan or a pharmaceutically acceptable salt thereof is in the form of a solvate.

[0385] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is present in a substantially amorphous form (e.g., >75%, >80%, >85%, >90%, >95%, >98%, >99%, or >99.5% amorphous). For example, in some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is amorphous atrasentan hydrochloride (as described in WO 2006 / 034085).

[0386] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, exists in one or more crystalline forms ("polymorphs," e.g., >75%, >80%, >85%, >90%, >95%, >98%, >99%, or >99.5% crystalline). For example, in some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is atrasentan hydrochloride Form 1 (described in WO 2006 / 034094). In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is atrasentan hydrochloride Form 2 (described in WO 2006 / 034084). In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is atrasentan hydrochloride Form 3 (described in WO 2006 / 034234 and U.S. Pat. No. 9,051,301).

[0387] In certain embodiments, the crystalline atrasentan mandelate is crystalline atrasentan (S)-mandelate. In certain embodiments, the atrasentan (S)-mandelate is an anhydrous salt. In certain embodiments, the atrasentan (S)-mandelate is a solvated salt. In certain embodiments, the atrasentan (S)-mandelate is a solvated salt selected from the group consisting of an acetonitrile solvate, an ethanol solvate, and a pyridine solvate. In certain embodiments, the atrasentan (S)-mandelate is a hydrated salt.

[0388] In certain embodiments, the crystalline atrasentan (S)-mandelate is crystalline atrasentan (S)-mandelate, wherein the molar ratio of atrasentan to (S)-mandelate is about 1:1. In certain embodiments, the atrasentan (S)-mandelate is an anhydrous salt. In certain embodiments, the atrasentan (S)-mandelate is a solvated salt. In certain embodiments, the atrasentan (S)-mandelate is a solvated salt selected from the group consisting of an acetonitrile solvate, an ethanol solvate, and a pyridine solvate. In certain embodiments, the atrasentan (S)-mandelate is a hydrated salt. In certain embodiments, the atrasentan or a pharmaceutically acceptable salt thereof is substantially crystalline atrasentan (S)-mandelate, wherein the molar ratio of atrasentan to (S)-mandelate is about 1:1.

[0389] In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, and 19.4±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, 12.1±0.2, and 19.4±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, 12.1±0.2, 18.0±0.2, 18.4±0.2, and 19.4±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the experimental error associated with the X-ray powder diffraction peak values ​​listed in the various embodiments above is ±0.1 degrees 2θ. In certain embodiments, the crystalline (S)-mandelate salt is an anhydrous salt. In certain embodiments, the molar ratio of atrasentan to (S)-mandelate salt is about 1:1.

[0390] In certain embodiments, the crystalline (S)-mandelate salt has an orthorhombic lattice structure. In certain embodiments, the crystalline (S)-mandelate salt has a P212121 space group. In certain embodiments, the crystalline (S)-mandelate salt has unit cell a, b, and c values ​​of about 9.954 Å, about 11.049 Å, and about 30.861 Å, respectively. In certain embodiments, the crystalline (S)-mandelate salt has unit cell α, β, and γ values ​​of about 90°, about 90°, and about 90°, respectively. In certain embodiments, the crystalline (S)-mandelate salt has at least three of the following characteristics: (a) an orthorhombic lattice structure; (b) a P212121 space group; (c) unit cell a, b, and c values ​​of about 9.954 Å, about 11.049 Å, and about 30.861 Å, respectively; and / or (d) unit cell α, β, and γ values ​​of about 90°, about 90°, and about 90°, respectively. In certain embodiments, the crystalline (S)-mandelate salt has: (a) an orthorhombic lattice structure; (b) a P212121 space group; (c) unit cell a, b, and c values ​​of about 9.954 Å, about 11.049 Å, and about 30.861 Å, respectively; and (d) unit cell α, β, and γ values ​​of about 90°, about 90°, and about 90°, respectively. In certain embodiments, the crystalline (S)-mandelate salt is an anhydrous salt. In certain embodiments, the molar ratio of atrasentan to (S)-mandelate is about 1:1.

[0391] In certain embodiments, the crystalline (S)-mandelate salt is crystalline atrasentan (S)-mandelate salt, wherein the molar ratio of atrasentan to (S)-mandelate salt is about 2:1. In certain embodiments, the crystalline atrasentan (S)-mandelate salt is an anhydrous salt. In certain embodiments, the crystalline atrasentan (S)-mandelate salt is a solvated salt. In certain embodiments, the crystalline atrasentan (S)-mandelate salt is a hydrated salt. In certain embodiments, the atrasentan or pharmaceutically acceptable salt thereof is substantially crystalline atrasentan (S)-mandelate salt, wherein the molar ratio of atrasentan to (S)-mandelate salt is about 2:1.

[0392] In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, and 18.1±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, 18.1±0.2, and 18.7±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the crystalline (S)-mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, 9.1±0.2, 18.1±0.2, and 18.7±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the experimental error associated with the X-ray powder diffraction peak values ​​listed in the various embodiments above is ±0.1 degrees 2θ. In certain embodiments, the crystalline (S)-mandelate salt is an anhydrous salt. In certain embodiments, the crystalline (S)-mandelate salt is a hydrated salt.

[0393] In certain embodiments, the crystalline atrasentan mandelate is crystalline atrasentan (R)-mandelate. In certain embodiments, the crystalline atrasentan (R)-mandelate is an anhydrous salt. In certain embodiments, the crystalline atrasentan (R)-mandelate is a solvated salt. In certain embodiments, the crystalline atrasentan (R)-mandelate is a hydrated salt.

[0394] In certain embodiments, the crystalline atrasentan (R)-mandelate is crystalline atrasentan (R)-mandelate, wherein the molar ratio of atrasentan to (R)-mandelate is about 1:1. In certain embodiments, the crystalline atrasentan (R)-mandelate is an anhydrous salt. In certain embodiments, the crystalline atrasentan (R)-mandelate is a solvated salt. In certain embodiments, the crystalline atrasentan (R)-mandelate is a hydrated salt. In certain embodiments, the atrasentan or a pharmaceutically acceptable salt thereof is substantially crystalline atrasentan (R)-mandelate, wherein the molar ratio of atrasentan to (R)-mandelate is about 1:1.

[0395] In certain embodiments, crystalline atrasentan (R)-mandelate has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 11.8±0.2, and 20.9±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, crystalline atrasentan (R)-mandelate has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 8.2±0.2, 11.8±0.2, and 20.9±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, crystalline atrasentan (R)-mandelate has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 8.2±0.2, 8.6±0.2, 11.8±0.2, and 20.9±0.2 degrees two-theta when measured using monochromatic Kα1 radiation at about 25° C. In certain embodiments, the experimental error associated with the X-ray powder diffraction peak values ​​listed in the various embodiments above is ±0.1 degrees 2θ. In certain embodiments, the crystalline atrasentan (R)-mandelate salt is an anhydrous salt.

[0396] In some embodiments, the atrasentan or pharmaceutically acceptable salt thereof comprises amorphous atrasentan mandelate. In certain embodiments, the atrasentan or pharmaceutically acceptable salt thereof is substantially amorphous atrasentan mandelate.

[0397] In certain embodiments, the amorphous atrasentan mandelate is amorphous atrasentan (S)-mandelate. In certain embodiments, the amorphous atrasentan (S)-mandelate is an anhydrous salt. In certain embodiments, the amorphous atrasentan (S)-mandelate is a solvated salt. In certain embodiments, the amorphous atrasentan (S)-mandelate is a solvated salt selected from the group consisting of an acetonitrile solvate, an ethanol solvate, and a pyridine solvate. In certain embodiments, the amorphous atrasentan (S)-mandelate is a hydrated salt. In certain embodiments, the amorphous atrasentan (S)-mandelate has a molar ratio of atrasentan to (S)-mandelate of about 1:1. In certain embodiments, the amorphous atrasentan (S)-mandelate has a molar ratio of atrasentan to (S)-mandelate of about 2:1.

[0398] In certain embodiments, the amorphous atrasentan mandelate is amorphous atrasentan (R)-mandelate. In certain embodiments, the amorphous atrasentan (R)-mandelate is an anhydrous salt. In certain embodiments, the amorphous atrasentan (R)-mandelate is a solvated salt. In certain embodiments, the amorphous atrasentan (R)-mandelate is a solvated salt selected from the group consisting of an acetonitrile solvate, an ethanol solvate, and a pyridine solvate. In certain embodiments, the amorphous atrasentan (R)-mandelate is a hydrated salt. In certain embodiments, the amorphous atrasentan (R)-mandelate has a molar ratio of atrasentan to (R)-mandelate of about 1:1. In certain embodiments, the amorphous atrasentan (R)-mandelate has a molar ratio of atrasentan to (R)-mandelate of about 2:1.

[0399] Crystalline and amorphous atrasentan mandelate salts are described in more detail in US Pat. Nos. 8,962,675 and 9,637,476.

[0400] D. Preparations and Kits The term "pharmaceutical composition" as used herein is intended to encompass a product containing an active ingredient and an inactive ingredient that constitutes a carrier, as well as any product resulting directly or indirectly from the combination, complex formation or aggregation of any two or more of the ingredients, or the dissociation of one or more of the ingredients, or any other type of reaction or interaction of one or more of the ingredients. Thus, the pharmaceutical composition of the present disclosure encompasses any composition made by mixing a compound of the present disclosure, or a pharmaceutically acceptable salt thereof, or a solvate or solvate of a salt thereof, with a pharmaceutically acceptable carrier.

[0401] To prepare pharmaceutical or sterile compositions, the active agent is typically mixed with a pharmaceutically acceptable carrier or excipient. See, e.g., Remington's Pharmaceutical Sciences and US Pharmacopeia: National Formulary, Mack Publishing Company, Easton, PA (1984). Formulations of one or more active agents can be prepared by mixing with physiologically acceptable carriers, excipients, or stabilizers, for example, in the form of a lyophilized powder, a slurry, an aqueous solution, or a suspension (see, e.g., Hardman, et al., 2001, Goodman and Gilman's The Pharmacological Basis of Therapeutics, McGraw-Hill, New York, NY; Gennaro, 2000, Remington: The Science and Practice of Pharmacy, Lippincott, Williams, and Wilkins, New York, NY; Avis, et al. (eds.), 1993, Pharmaceutical Dosage Forms: Parenteral Medications, Marcel Dekker, NY; Lieberman, et al. (eds.), 1990, Pharmaceutical Dosage Forms: Tablets, Marcel Dekker, NY; Lieberman, et al. (eds.), 1990, Pharmaceutical Dosage Forms: Forms: Disperse Systems, Marcel Dekker, NY; Weiner and Kotkoskie, 2000, Excipient Toxicity and Safety, Marcel Dekker, Inc., New York, NY).

[0402] In some embodiments, a kit is provided, comprising an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL binding antibody, or antigen-binding fragment thereof, wherein the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, may be in the same and / or separate dosage forms. In some embodiments, the kit may further comprise an SGLT-2 inhibitor.

[0403] In some embodiments, a kit is provided, the kit comprising an SGLT-2 inhibitor and an APRIL binding antibody, or antigen-binding fragment thereof, wherein the SGLT-2 inhibitor and the APRIL binding antibody, or antigen-binding fragment thereof, may be in the same and / or separate dosage forms.

[0404] Exemplary Formulations of APRIL-Binding Antibodies, or Antigen-Binding Fragments Thereof In some embodiments, a sterile liquid formulation of an APRIL binding antibody, or antigen-binding fragment thereof, is provided.

[0405] Exemplary formulations of APRIL-binding antibodies, or antigen-binding fragments thereof, and methods of making the same are further described in US Pat. Nos. 9,364,458 and 10,016,393.

[0406] Exemplary Dosage Forms of Endothelin Receptor Antagonists In some embodiments, provided herein is a stable solid pharmaceutical dosage form comprising an endothelin receptor antagonist and a pharmaceutically acceptable diluent.

[0407] Suitable diluents for use in the described dosage forms include, but are not limited to, lactose (such as lactose monohydrate, lactose anhydrous, and PHARMATOSE® DCL21), sucrose, glucose, mannitol, sorbitol, isomalt, microcrystalline cellulose (such as AVICEL® PH101 and AVICEL® PH102), silicified microcrystalline cellulose (such as PROSOLV® SMCC 50 and SMCC 90), dicalcium phosphate, starch, and combinations thereof. In some embodiments, the diluent is selected from the group consisting of lactose, mannitol, isomalt, microcrystalline cellulose, dicalcium phosphate, and combinations thereof. In some embodiments, the diluent is lactose.

[0408] In some embodiments, the weight percent of the diluent in the dosage form is about 70% to about 99% by weight. In some embodiments, the weight percent of the diluent in the dosage form is about 80% to about 99% by weight. In some embodiments, the weight percent of the diluent in the dosage form is about 85% to about 99% by weight. In certain of the foregoing embodiments, the diluent is selected from the group consisting of lactose, mannitol, isomalt, and combinations thereof. As a non-limiting example, the diluent can be lactose.

[0409] In some embodiments, the endothelin receptor antagonist is atrasentan, or a pharmaceutically acceptable salt thereof. In some embodiments, the endothelin receptor antagonist is sparsentan, or a pharmaceutically acceptable salt thereof.

[0410] In some embodiments, provided herein is a stable solid pharmaceutical dosage form comprising about 200 mg to about 1,000 mg of sparsentan, or an equivalent amount of a pharmaceutically acceptable salt thereof.

[0411] In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising: (a) about 0.25 mg to about 1.25 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof, wherein the weight percentage of atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is about 0.05% to about 2.0% by weight, based on the atrasentan free base equivalent; and (b) a pharmaceutically acceptable diluent.

[0412] In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising: (a) about 0.25 mg to about 1.25 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof, wherein the weight percentage of atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is about 0.05% by weight to about 2.0% by weight, based on the atrasentan free base equivalent; (b) a pharmaceutically acceptable antioxidant, wherein the molar ratio of the antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 10:1 to about 1:10; and (c) a pharmaceutically acceptable diluent.

[0413] The dosage form can comprise atrasentan free base, a pharmaceutically acceptable salt of atrasentan, or a combination thereof. In some embodiments, the dosage form comprises atrasentan free base. In some embodiments, the dosage form comprises a pharmaceutically acceptable salt of atrasentan. In some embodiments, the dosage form comprises atrasentan hydrochloride. In some embodiments, the dosage form comprises atrasentan hydrochloride having a polymorphic form selected from the group consisting of atrasentan hydrochloride Form 1, atrasentan hydrochloride Form 2, and atrasentan hydrochloride Form 3. In some embodiments, the dosage form comprises amorphous atrasentan hydrochloride. In some embodiments, the dosage form comprises atrasentan hydrochloride Form 1. In some embodiments, the dosage form comprises atrasentan hydrochloride Form 2. In some embodiments, the dosage form comprises atrasentan hydrochloride Form 3. In some embodiments, the dosage form comprises atrasentan mandelate. In certain embodiments, the dosage form comprises crystalline atrasentan mandelate (e.g., crystalline atrasentan (S)-mandelate and / or crystalline atrasentan (R)-mandelate). In certain embodiments, the dosage form comprises amorphous atrasentan mandelate (e.g., amorphous atrasentan (S)-mandelate and / or amorphous atrasentan (R)-mandelate). In certain of the foregoing embodiments (where the dosage form comprises crystalline and / or amorphous atrasentan (S)- and / or (R)-mandelate), the molar ratio of atrasentan to mandelate is 1:1. In certain other embodiments, the molar ratio of atrasentan to mandelate is 2:1.

[0414] In some embodiments, the dosage form contains about 0.25 mg to about 1.25 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form contains about 0.40 mg to about 1.00 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form contains about 0.40 mg to about 0.85 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form contains about 0.50 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form contains about 0.75 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof.

[0415] In some embodiments, the dosage form contains about 0.25 mg to about 1.25 mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form contains about 0.40 mg to about 1.00 mg of atrasentan, or an equivalent amount of atrasentan hydrochloride. In some embodiments, the dosage form contains about 0.40 mg to about 0.85 mg of atrasentan, or an equivalent amount of atrasentan hydrochloride. In some embodiments, the dosage form contains about 0.50 mg of atrasentan, or an equivalent amount of atrasentan hydrochloride. In some embodiments, the dosage form contains about 0.75 mg of atrasentan, or an equivalent amount of atrasentan hydrochloride.

[0416] In some embodiments, the dosage form further comprises a pharmaceutically acceptable disintegrant, wherein the weight-to-weight ratio of the disintegrant to the antioxidant (e.g., L-cysteine), or a pharmaceutically acceptable salt or ester thereof, is about 60:1 to about 3:1. In some embodiments, the weight-to-weight ratio of the disintegrant to the antioxidant (e.g., L-cysteine), or a pharmaceutically acceptable salt or ester thereof, is about 50:1 to about 4:1. In some embodiments, the weight-to-weight ratio of the disintegrant to the antioxidant (e.g., L-cysteine), or a pharmaceutically acceptable salt or ester thereof, is about 35:1 to about 5:1.

[0417] Antioxidants suitable for use in the described dosage forms include antioxidants that function as reducing agents and are oxidized to pharmaceutically acceptable reduction products in the dosage form. In some embodiments, the antioxidant has an oxidation-reduction potential less than that of atrasentan (i.e., less than about 900 mV) and greater than about 550 mV. In some embodiments, the antioxidant has an oxidation-reduction potential less than about 550 mV. In some embodiments, the antioxidant has an oxidation-reduction potential of about 1 mV to about 550 mV. In some embodiments, the solubility of the antioxidant in water at about 25°C is greater than about 24 mg / mL. In some embodiments, the antioxidant is an amino acid, or a pharmaceutically acceptable salt or ester thereof. In some embodiments, the antioxidant is cysteine. In some embodiments, the antioxidant is L-cysteine, or a pharmaceutically acceptable salt or ester thereof. In some embodiments, the antioxidant is selected from the group consisting of L-cysteine ​​hydrochloride monohydrate, L-cysteine ​​hydrochloride anhydrous, and L-cysteine ​​ethyl ester. In some embodiments, the dosage form comprises L-cysteine ​​hydrochloride monohydrate.

[0418] In some embodiments, the weight percent of the antioxidant in the dosage form is about 0.05% to about 1.0% by weight. In some embodiments, the weight percent of the antioxidant in the dosage form is about 0.07% to about 0.7% by weight. In some embodiments, the weight percent of the antioxidant in the dosage form is about 0.09% to about 0.5% by weight.

[0419] In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 10:1 to about 1:10. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is about 5:1 to about 1:5. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 2:1 to about 1:2. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 1:1.

[0420] In some embodiments, the antioxidant is L-cysteine ​​or a pharmaceutically acceptable salt thereof. In certain embodiments, the weight percent of L-cysteine, or a pharmaceutically acceptable salt or ester thereof, in the dosage form is about 0.05% to about 1.0% by weight. In certain embodiments, the weight percent of L-cysteine, or a pharmaceutically acceptable salt or ester thereof, in the dosage form is about 0.07% to about 0.7% by weight. In certain embodiments, the weight percent of L-cysteine, or a pharmaceutically acceptable salt or ester thereof, in the dosage form is about 0.09% to about 0.5% by weight.

[0421] In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.25 mg to about 1.25 mg of atrasentan or a pharmaceutically acceptable salt thereof (e.g., atrasentan hydrochloride) based on the atrasentan parent equivalent weight. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.40 mg to about 1.00 mg of atrasentan or a pharmaceutically acceptable salt thereof (e.g., atrasentan hydrochloride) based on the atrasentan parent equivalent weight. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.50 mg of atrasentan or a pharmaceutically acceptable salt thereof (e.g., atrasentan hydrochloride) based on the atrasentan parent equivalent weight. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.75 mg of atrasentan or a pharmaceutically acceptable salt thereof (e.g., atrasentan hydrochloride) based on the atrasentan parent equivalent weight.

[0422] In certain of the foregoing embodiments, the dosage form is a tablet.

[0423] In some embodiments, a kit is provided that includes: (a) a pharmaceutical composition comprising an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof; (b) an APRIL-binding antibody, or an antigen-binding fragment thereof; and (c) instructions for use.

[0424] E. Dosage and Administration In some embodiments, the dose of an APRIL-binding antibody or antigen-binding fragment thereof is about 4 mg / kg to about 15 mg / kg, e.g., about 4 mg / kg, about 4.5 mg / kg, about 5 mg / kg, about 5.5 mg / kg, about 6 mg / kg, about 6.5 mg / kg, about 7 mg / kg, about 7.5 mg / kg, about 8 mg / kg, about 8.5 mg / kg, about 9 mg / kg, about 9.5 mg / kg, about 10 mg / kg, about 10.5 mg / kg, about 11 mg / kg, about 11.5 mg / kg, about 12 mg / kg, about 12.5 mg / kg, about 13 mg / kg, about 13.5 mg / kg, about 14 mg / kg, about 14.5 mg / kg, or about 15 mg / kg. In some embodiments, the dose of an APRIL-binding antibody or antigen-binding fragment thereof is about 4 mg / kg to about 10 mg / kg. In some embodiments, the dose of the APRIL-binding antibody, or antigen-binding fragment thereof, is about 8 mg / kg to about 12 mg / kg, hi some embodiments, the dose of the APRIL-binding antibody, or antigen-binding fragment thereof, is about 10 mg / kg to about 15 mg / kg.

[0425] In some embodiments, the total dose of the APRIL-binding antibody, or antigen-binding fragment thereof, is about 450 mg to about 600 mg. In some embodiments, the total dose of the APRIL-binding antibody, or antigen-binding fragment thereof, is 450 mg or 600 mg.

[0426] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered parenterally. Parenteral administration refers to methods of administration other than enteral and topical administration, usually by injection, and includes epidermal, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, intratendinous, transtracheal, subcutaneous, subcuticular, intra-articular, subcapsular, subarachnoid, intraspinal, intracranial, intrathoracic, epidural, and intrasternal injection and infusion. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by intravenous injection or infusion. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by intravenous infusion. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by intravenous injection. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by subcutaneous injection.

[0427] In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once a week. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered every other week (i.e., once every two weeks). In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once every three weeks. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once a month.

[0428] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered at the approved dose of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof.

[0429] In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is sparsentan or a pharmaceutically acceptable salt thereof, and sparsentan is administered in a dose of about 200 mg to about 1,000 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, sparsentan is administered in a dose of about 200 mg to about 600 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, sparsentan is administered in a dose of about 400 mg to about 800 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, sparsentan is administered in a dose of 200 mg, 400 mg, or 600 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof.

[0430] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is atrasentan, or a pharmaceutically acceptable salt thereof, and the atrasentan is administered at a dose of about 0.10 mg to about 1.50 mg (e.g., about 0.10, about 0.20, about 0.30, about 0.40, about 0.50, about 0.60, about 0.70, about 0.75, about 0.80, about 0.90, about 1.00, about 1.10, about 1.20, about 1.30, about 1.40, about 1.50, or any value therebetween) of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.75 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.25 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.35 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.00 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.25 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.50 mg, or an equivalent amount of a pharmaceutically acceptable salt thereof.

[0431] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered orally, for example, as a tablet or capsule.

[0432] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered once daily. In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered every other day.

[0433] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered more than once daily, such as in divided doses. In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered once daily. For example, in some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of about 0.75 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of 0.75 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of about 0.25 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of 0.25 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of about 0.35 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of 0.35 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of about 1.00 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of 1.00 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of about 1.50 mg of atrasentan free base once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to a subject at a dose of 1.50 mg of atrasentan free base once daily.

[0434] In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, is administered in a therapeutically effective amount. In some embodiments, the APRIL binding antibody, or antigen-binding fragment thereof, is administered in a therapeutically effective amount. In some embodiments, the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL binding antibody, or antigen-binding fragment thereof, when administered together, provide therapeutically effective amounts.

[0435] Toxicity and therapeutic efficacy of active agents can be determined in cell cultures or experimental animals by standard pharmaceutical procedures, for example, to determine the LD50 (the dose lethal in 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index, which can be expressed as the ratio between LD50 and ED50. Data obtained from these cell culture assays and animal studies can be used in formulating a range of dosages for use in humans. The dosage of such compounds lies preferably within a range of circulating concentrations that include the ED50 with little or no toxicity. Dosages can vary within this range depending on the dosage form employed and the route of administration utilized.

[0436] Suitable routes of administration include parenteral administration, such as intramuscular, intravenous, or subcutaneous administration, and oral administration. Administration of antibodies used in pharmaceutical compositions or used to practice the methods of the present disclosure can be carried out in a variety of conventional ways, such as oral ingestion, inhalation, topical application, or cutaneous, subcutaneous, intraperitoneal, parenteral, intraarterial, or intravenous injection. In one embodiment, an antibody of the present disclosure is administered intravenously. In another embodiment, an antibody of the present disclosure is administered subcutaneously. In one embodiment, an endothelin receptor agonist and / or an SGLT-2 inhibitor is administered orally.

[0437] A preferred dosing protocol involves the maximum dose or dosing frequency of the combination therapy that achieves the desired therapeutic effect (e.g., reduction in IgA levels) while avoiding significant undesirable side effects. Administration of the anti-APRIL antibodies, or antigen-binding fragments thereof, described herein can be by either intravenous or subcutaneous injection (e.g., into the thigh, abdomen, upper arm, etc.) about once per week, about once per 2 weeks, about once per 3 weeks, about once per 4 weeks, about once per 8 weeks, etc. The dose per injection or infusion can be about 10 to 1350 mg, e.g., about 50 mg, about 150 mg, about 300 mg, about 450 mg, about 600 mg, about 750 mg, about 1000 mg, or about 1350 mg. In certain embodiments, administration of the anti-APRIL antibody, or antigen-binding fragment thereof, is by subcutaneous injection, with a dose of about 600 mg per administration event ("administration event" refers to one or more deliveries, such as injections, intended to provide a single administration to an individual, where the administrations occur at the same or different sit...

Claims

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

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

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

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

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

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

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

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

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

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

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

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

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

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

15. the APRIL-binding antibody, or antigen-binding fragment thereof, (a) a heavy chain complementarity determining region 1 (HC CDR1) comprising the amino acid sequence of SEQ ID NO: 1; (b) a heavy chain complementarity determining region 2 (HC CDR2) comprising the amino acid sequence of SEQ ID NO: 2; (c) a heavy chain complementarity determining region 3 (HC CDR3) comprising the amino acid sequence of SEQ ID NO: 3; (d) a light chain complementarity-determining region 1 (LC CDR1) comprising the amino acid sequence of SEQ ID NO: 4; (e) a light chain complementarity-determining region 2 (LC CDR2) comprising the amino acid sequence of SEQ ID NO: 5; and (f) a light chain complementarity determining region 3 (LC CDR3) comprising the amino acid sequence of SEQ ID NO:

6.

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

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

26.

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

26.

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

28.

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

30.

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

30.

22. 22. The method of any one of claims 1 to 21, wherein the APRIL-binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising one of SEQ ID NOs: 7, 9, 11, 13, 15, 17, 19, 21, or 23.

23. 23. The method of any one of claims 1 to 22, wherein the APRIL-binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising one of SEQ ID NOs: 25, 27, 29, 31, or 33.

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

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

26. the method comprises repeating the administration of the APRIL-binding antibody, or antigen-binding fragment thereof, on an at least weekly (QW) schedule for at least two administration cycles; or the method comprises repeating the administration of the APRIL-binding antibody, or antigen-binding fragment thereof, on a schedule of at least once every two weeks (Q2W) for at least two administration cycles; or 26. The method of any one of claims 1 to 25, wherein the method comprises repeating the administration of the APRIL-binding antibody, or antigen-binding fragment thereof, on a schedule of at least once every four weeks (Q4W) or once a month (QMT) for at least two administration cycles.

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

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

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

30. The kit comprises an endothelin receptor antagonist, or a pharmaceutical salt thereof, and an APRIL-binding antibody, or an antigen-binding fragment thereof, wherein the endothelin receptor antagonist, or a pharmaceutical salt thereof, and the APRIL-binding antibody, or an antigen-binding fragment thereof, may be in the same and / or separate dosage forms.

Images