Dr. Kirk Campbell on the PODOCYTE Study October 1, 2018 by Lauren Eva We chatted recently with Dr. Campbell, a Principal Investigator for the PODOCYTE Study, to learn more about the trial, what it involves, and for which patients it might be best suited. NephCure Kidney International: What is the PODOCYTE Study, and what is involved for patients who want to participate? Dr. Kirk Campbell: The PODOCYTE Study is designed to test the efficacy [or effectiveness] of Acthar gel in primary Focal Segmental Glomerulosclerosis. To qualify for the study, patients need to be either resistant or intolerant to other treatments for FSGS. This study specifically targets patients whose FSGS is difficult to treat and who are at a higher risk for disease progression. NephCure: Is this drug different from steroids or other commonly-prescribed treatments for FSGS? Dr. Campbell: The study drug, Acthar gel, has been approved for the treatment of Nephrotic Syndrome for several decades, but the exact dose and duration of therapy, as well as the appropriate patient population within the spectrum of FSGS to administer the medication to, has not been that clear. This study seeks to get closer to answering those important questions. The drug does not function exclusively like a steroid; there are steroid-like effects and anti-inflammatory effects, but one of the ways that this drug may work is by directly targeting specific melanocotin receptors on podocytes, the key target cell for injury in FSGS. NephCure: Do you think it matters that researchers don’t know specifically why or why not this drug works? Dr. Campbell: It’s a good question, but for every other drug we currently use for FSGS, we don’t completely understand why they work for this specific disease. All of the agents that we currently use are repurposed drugs from other clinical indications [i.e., created for use with other conditions], so this is a field that is really in need of innovation. But in the meantime, we have to make the best use of available, approved therapies, meaning drugs like this one and others, including cyclosporine, rituximab, and steroids, even if they weren’t approved specifically for FSGS. NephCure: In this study, all the patients will receive the Acthar gel treatment. How does this work? Dr. Campbell: All patients entering this study get the study drug, Acthar gel, upfront, and those who have a significant positive clinical response will have the option of entering an extended period where they would be randomized to the drug versus placebo. Those that don’t respond during the initial phase will be eligible for an extended, open-label enrollment where they will get the treatment. So all patients will have the opportunity to get the drug, and they’ll all be monitored closely and assessed for a clinical response. The information that we’ll get from this study will be very helpful and will benefit all patients with this disorder in the long run. NephCure: How long do you wait for a response before moving a patient into the drug versus placebo stage? Dr. Campbell: The initial part (6 months) is open label, and then, depending on the patient response, they would go to a second phase which would be drug versus placebo. That second phase is designed more to assess whether continuing treatment is necessary to maintain a remission, so only the patients who respond would potentially be in the second-phase placebo group. In clinical practice some nephrologists use this drug for 6 months, and there are some that use it for 12 months. For patients who respond after 6 months of therapy, the question is: do you just stop treatment and monitor them, or should you continue the treatment to maintain that remission? This trial is designed to answer that very question—what to do with patients who respond after six months of treatment with Acthar for FSGS? NephCure: I understand that Acthar gel is given as an injection—do you have to go in for the injection, or can you take it at home? Dr. Campbell: Patients take it at home; they can administer it themselves. When the medication is being dispensed, they’ll receive a really nice handout with pictures and very clear instructions about administering the agent subcutaneously. The first dose is also administered at the study site under physician supervision. NephCure: There are a lot of medical institutions in the greater New York City area. How do you partner with other nephrologists to spread the word about these clinical trial opportunities? For example, if there’s a patient who’s interested in participating who isn’t treated at Mount Sinai, is there a way for them to participate? Dr. Campbell: Absolutely. In fact, the very first patient we enrolled in this study was not followed at Mount Sinai—she came from a colleague at a different institution who contacted me while exploring treatment options for steroid-resistant FSGS. What we tell nephrologists and patients is that we are not seeking to disrupt the continuity of care and follow-up in well-established relationships between the patients and their nephrologists. We are only offering the opportunity to engage in studies that are well-controlled and can possibly offer a therapeutic benefit in patients who have treatment-resistant FSGS. We will see patients in their study visits, but outside of that, they maintain their relationship with their outpatient nephrology physician. NephCure: Why is it important for minorities and people of color to participate in clinical research, and especially, the FSGS population? Dr. Campbell: That’s an excellent question. First, participation in clinical trials has traditionally lagged among patients from underrepresented minority backgrounds. That goes for trials in nephrology as well as in many other fields within medicine. It’s particularly important for this study because FSGS is far more prevalent in patients from underrepresented backgrounds.. [African Americans are four times as likely to develop FSGS than European Americans.] The prognosis can also be worse, with higher rates of progression towards end stage renal disease. So it is especially important for patients from minority backgrounds to be aware of studies like this and to take advantage of the enrollment and the close monitoring that’s involved. NephCure: In your experience, what’s the biggest obstacle or fear that patients have about volunteering for clinical research, and how do you address or alleviate their concerns? Dr. Campbell: I think patients often have a lot of questions. They want to be aware of all the different treatment options available and want to be comfortable that they’re not being swayed in a particular direction that could negatively impact their health. Patients also often want to use therapeutic options that have been time-tested, ones that have been proven to work with minimal side effects. Inherently in clinical studies, often-times the side effect profile of the drug hasn’t been clearly established, so patients can be a bit concerned about that. Finally, a lot of them will say that they don’t want to be guinea pigs, that they don’t want to be experimented on, for fear again of negative outcomes. But patients get the closest monitoring when they’re in a trial: Every symptom and every new medication that they take must be clearly described and documented by the research team. Patients enrolled in clinical trials, because of the close scrutiny on them, end up getting excellent medical care and are watched much more closely than they would oftentimes be in routine clinical practice. Furthermore, there is an opportunity to try a therapy that can often work better than the traditional options. We try to reassure them with those realities. NephCure: Final thoughts—what would you say to someone who’s on the fence about participating in this study? Dr. Campbell: There are currently no clinically-approved drugs specific for FSGS. The drug being tested in this trial has been approved for Nephrotic Syndrome, and it is a therapeutic option that will be better understood by a study like this. For this disease, we don’t have a lot of options when patients don’t respond or don’t tolerate the first-line therapy. Participation in trials like this one can help us all understand how to better treat our FSGS patients. We encourage you to learn more about the PODOCYTE Study and other studies that might be right for you at kidneyhealthgateway.com. Kirk Campbell, MD, is an Associate Professor in the Division of Nephrology and the Vice Chair of Diversity and Inclusion at the Icahn School of Medicine at Mount Sinai. He is also the Director of the Nephrology Fellowship Program and an Ombudsperson for medical students. He is board certified in Nephrology. Dr. Campbell is a graduate of the University of Connecticut School of Medicine and completed his residency training in Internal Medicine at Yale-New Haven Hospital and a clinical and research fellowship in Nephrology at The Mount Sinai Hospital. In addition to treating patients with renal disease, Dr. Campbell leads an NIH-funded research program focused on understanding the mechanism of podocyte injury in the progression of proteinuric kidney diseases. He is a NephCure Young Investigator Awardee and a recipient of the Carl Gottschalk Research Scholar Grant from the American Society of Nephrology. Dr. Campbell is a member of the Medical Advisory Board of the National Kidney Foundation Serving Greater New York.