Predicted Dose-Response to Combination of Zibotentan with Fixed-Dose
Dapagliflozin in the ZENITH Trial Population: A Mathematical Modeling
Analysis
Abstract
Background and Purpose: Selective endothelin A (ETA) antagonism has
shown promise as a potential treatment for chronic kidney disease (CKD),
but the adverse effect of fluid retention associated with ETA
antagonists has limited their clinical utility. Combination of low doses
of the selective ETA antagonist zibotentan with a fixed-dose
sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin is
currently being evaluated in the Zibotentan and Dapagliflozin for the
Treatment of CKD (ZENITH-CKD) clinical trial as an approach to maximize
kidney protection via ETA antagonism and SGLT2 inhibition in
combination. Approach: This study utilized a quantitative systems
pharmacology modeling approach to simulate the dose-response
relationship of zibotentan alone and in combination with dapagliflozin
in a virtual CKD patient population. Key Results: Simulations predict
that interstitial fluid volume (IFV) changes will remain below baseline
for zibotentan doses below 0.5 mg when combined with dapagliflozin,
while the combination therapy will provide substantial additional
improvements in urinary albumin-to-creatinine ratio (uACR), glomerular
hypertension, and proximal tubule energy demand, indicating enhanced
renoprotection. The simulation also indicate that patients with higher
baseline eGFR (>30 mL/min/1.73m2) and baseline uACR
(>800 mg/g) may experience greater kidney protective
response to the combination therapy with less potential for detrimental
fluid retention. Conclusions and impact: If the predicted results are
confirmed by the ZENITH-CKD trial, this analysis will enhance
mechanistic understanding of the balance between albuminuria reduction
and fluid retention with this combination treatment strategy, and will
provide a tool to inform optimal population selection for late phase
clinical studies and lifecycle management planning.