Strategies Using Darbepoetin Alfa to Avoid Transfusions in Chronic Kidney Disease (START-CKD)

September 8, 2022 updated by: Amgen
A phase 3, multicenter, randomized, double-blind, parallel group study. Anemic subjects with chronic kidney disease (CKD) and not on dialysis will be randomized 1:1 to 1 of 2 dosing strategies to evaluate the proportion of subjects receiving at least one red blood cell (RBC) transfusion. In the haemoglobin (Hb)-based titration group, darbepoetin alfa doses will be titrated to maintain Hb ≥ 10.0 grams/deciliter (g/dL). In the fixed dose group, subjects will receive a fixed dose of darbepoetin alfa. Treatment group, darbepoetin alfa doses, and protocol specified Hb concentrations will be blinded. Subjects will be followed for approximately 2 years from the date of randomization.

Study Overview

Detailed Description

The study is a phase 3, multicenter, randomized, double-blind, parallel group study designed to describe the benefits and potential risks of a new treatment strategy using a fixed dose of darbepoetin alfa in subjects with CKD and not on dialysis. Anemic subjects without recent use of an erythropoiesis stimulating agent (ESA) will be randomly allocated 1:1 to treatment with a fixed dose of darbepoetin alfa or to treatment with darbepoetin alfa using a Hb-based titration strategy, which has been the conventional dosing strategy. In the Hb-based titration group, darbepoetin alfa doses will be titrated to maintain Hb ≥ 10.0 g/dL. This study aims to estimate the incidence of RBC transfusions (administered as deemed clinically necessary) in each group and the difference in incidence of RBC transfusions between the 2 groups. In addition, multiple aspects, such as cumulative darbepoetin alfa dose, total number of units of transfusions, Hb concentration, Hb-related parameters (eg, Hb variability, excursions, rate of change), and adverse (eg, cardiovascular) events, will also be considered in order to determine a preferred dosing regimen. Treatment group, darbepoetin alfa doses, and protocol specified Hb concentrations will be blinded to the investigator, subjects and study team. Subjects will be followed for approximately 2 years from the date of randomization.

Study Type

Interventional

Enrollment (Actual)

756

Phase

  • Phase 3

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

      • Caguas, Puerto Rico, 00725
        • Research Site
      • Ponce, Puerto Rico, 00716
        • Research Site
      • Ponce, Puerto Rico, 00717
        • Research Site
      • Rio Piedras, Puerto Rico, 00935
        • Research Site
      • San Juan, Puerto Rico, 00909
        • Research Site
      • San Juan, Puerto Rico, 00918
        • Research Site
    • Alabama
      • Anniston, Alabama, United States, 36207
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      • Birmingham, Alabama, United States, 35235
        • Research Site
      • Huntsville, Alabama, United States, 35801
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      • Mobile, Alabama, United States, 36608
        • Research Site
      • Mobile, Alabama, United States, 36617
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      • Montgomery, Alabama, United States, 36106
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    • Arizona
      • Goodyear, Arizona, United States, 85395
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      • Peoria, Arizona, United States, 85381
        • Research Site
      • Phoenix, Arizona, United States, 85004
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      • Phoenix, Arizona, United States, 85032
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      • Phoenix, Arizona, United States, 85012
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      • Tempe, Arizona, United States, 85284
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    • Arkansas
      • Little Rock, Arkansas, United States, 72204
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    • California
      • Alhambra, California, United States, 91801
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      • Anaheim, California, United States, 92805
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      • Azusa, California, United States, 91702
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      • Bakersfield, California, United States, 93301
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      • Bakersfield, California, United States, 93309
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      • Bell Gardens, California, United States, 90201
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      • Beverly Hills, California, United States, 90211
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      • Cerritos, California, United States, 90703
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      • Chula Vista, California, United States, 91910
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      • Cudahy, California, United States, 90201
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      • El Centro, California, United States, 92243
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      • Fountain Valley, California, United States, 92708
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      • Fullerton, California, United States, 92835
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      • Garden Grove, California, United States, 92844
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      • Long Beach, California, United States, 90813
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      • Los Angeles, California, United States, 90025
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      • Los Angeles, California, United States, 90022
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      • Los Angeles, California, United States, 90015
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      • Modesto, California, United States, 95350
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      • Orange, California, United States, 92868
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      • Rancho Mirage, California, United States, 92270
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      • Redondo Beach, California, United States, 90277
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      • Riverside, California, United States, 92505
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      • Sacramento, California, United States, 95825
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      • San Dimas, California, United States, 91773
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      • Whittier, California, United States, 90603
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      • Whittier, California, United States, 90602
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      • Yuba City, California, United States, 95991
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    • Colorado
      • Arvada, Colorado, United States, 80002
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      • Westminster, Colorado, United States, 80031
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    • Connecticut
      • Middlebury, Connecticut, United States, 06762
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      • New Haven, Connecticut, United States, 06511
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      • North Haven, Connecticut, United States, 06473
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    • District of Columbia
      • Washington, District of Columbia, United States, 20037
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    • Florida
      • Boynton Beach, Florida, United States, 33472
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      • Coral Springs, Florida, United States, 33071
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      • Jacksonville, Florida, United States, 32216
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      • Jacksonville Beach, Florida, United States, 32250
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      • Lauderdale Lakes, Florida, United States, 33313
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      • Melbourne, Florida, United States, 32901
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      • Melbourne, Florida, United States, 32935
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      • Miami, Florida, United States, 33173
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      • Miami, Florida, United States, 33144
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      • Miami, Florida, United States, 33150
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      • Miami, Florida, United States, 33166
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      • Miami Beach, Florida, United States, 33140
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      • Naples, Florida, United States, 34110
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      • New Port Richey, Florida, United States, 34652
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      • New Port Richey, Florida, United States, 34653
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      • Orlando, Florida, United States, 32804
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      • Pembroke Pines, Florida, United States, 33028
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      • Port Charlotte, Florida, United States, 33952
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      • Summerfield, Florida, United States, 34491
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      • Tampa, Florida, United States, 33603
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      • Tampa, Florida, United States, 33612
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      • Tampa, Florida, United States, 33614
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    • Georgia
      • Atlanta, Georgia, United States, 30342
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      • Augusta, Georgia, United States, 30909
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      • Canton, Georgia, United States, 30114
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      • Macon, Georgia, United States, 31217
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      • Newnan, Georgia, United States, 30265
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    • Hawaii
      • Honolulu, Hawaii, United States, 96817
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    • Idaho
      • Meridian, Idaho, United States, 83642
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    • Illinois
      • Chicago, Illinois, United States, 60612
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      • Chicago, Illinois, United States, 60637
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      • Chicago, Illinois, United States, 60616
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      • Evanston, Illinois, United States, 60201
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      • Peoria, Illinois, United States, 61603
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      • Quincy, Illinois, United States, 62301
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    • Indiana
      • Columbus, Indiana, United States, 47201
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      • Michigan City, Indiana, United States, 46360
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    • Iowa
      • Ames, Iowa, United States, 50010
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    • Kansas
      • Kansas City, Kansas, United States, 66160
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      • Wichita, Kansas, United States, 67214-2998
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    • Kentucky
      • Lexington, Kentucky, United States, 40504
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      • Paducah, Kentucky, United States, 42003
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    • Louisiana
      • Baton Rouge, Louisiana, United States, 70808
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      • Lafayette, Louisiana, United States, 70503
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      • Metairie, Louisiana, United States, 70006
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      • Natchitoches, Louisiana, United States, 71457
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      • New Orleans, Louisiana, United States, 70112
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      • Ruston, Louisiana, United States, 71270
        • Research Site
      • Shreveport, Louisiana, United States, 71101
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    • Maine
      • Rockport, Maine, United States, 04856
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    • Maryland
      • Bethesda, Maryland, United States, 20814
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      • Oxon Hill, Maryland, United States, 20745
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    • Massachusetts
      • Framingham, Massachusetts, United States, 01702
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      • Plymouth, Massachusetts, United States, 02360
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      • Springfield, Massachusetts, United States, 01107
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    • Michigan
      • Flint, Michigan, United States, 48504
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      • Grand Rapids, Michigan, United States, 49525
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      • Kalamazoo, Michigan, United States, 49007
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      • Midland, Michigan, United States, 48640
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      • Pontiac, Michigan, United States, 48341
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      • Royal Oak, Michigan, United States, 48073
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      • Southgate, Michigan, United States, 48195
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    • Mississippi
      • Columbus, Mississippi, United States, 39705
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      • Gulfport, Mississippi, United States, 39501
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    • Missouri
      • Kansas City, Missouri, United States, 64114
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      • Kansas City, Missouri, United States, 64111
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      • Saint Peters, Missouri, United States, 63376
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    • Nebraska
      • Lincoln, Nebraska, United States, 68510
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      • North Platte, Nebraska, United States, 69101
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    • Nevada
      • Henderson, Nevada, United States, 89052
        • Research Site
      • Las Vegas, Nevada, United States, 89106
        • Research Site
    • New Jersey
      • Eatontown, New Jersey, United States, 07724
        • Research Site
      • Livingston, New Jersey, United States, 07039
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      • Toms River, New Jersey, United States, 08755
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      • Voorhees, New Jersey, United States, 08043
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    • New York
      • Albany, New York, United States, 12208
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      • Bronx, New York, United States, 10461
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      • Brooklyn, New York, United States, 11203
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      • Buffalo, New York, United States, 14215
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      • Flushing, New York, United States, 11355
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      • Great Neck, New York, United States, 11021
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      • Mineola, New York, United States, 11501
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      • New York, New York, United States, 10037
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      • Orchard Park, New York, United States, 14127
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      • Rochester, New York, United States, 14642
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      • Rosedale, New York, United States, 11422
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    • North Carolina
      • Asheville, North Carolina, United States, 28801
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      • Chapel Hill, North Carolina, United States, 27599
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      • Durham, North Carolina, United States, 27704
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      • Greensboro, North Carolina, United States, 27408
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      • Greenville, North Carolina, United States, 27834
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      • Kinston, North Carolina, United States, 28504
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      • Mooresville, North Carolina, United States, 28117
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      • New Bern, North Carolina, United States, 28562
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      • Statesville, North Carolina, United States, 28625
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      • Wilmington, North Carolina, United States, 28401
        • Research Site
      • Winston-Salem, North Carolina, United States, 27103
        • Research Site
      • Winston-Salem, North Carolina, United States, 27157
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    • North Dakota
      • Fargo, North Dakota, United States, 58103
        • Research Site
      • Fargo, North Dakota, United States, 58122
        • Research Site
      • Grand Forks, North Dakota, United States, 58201
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    • Ohio
      • Columbus, Ohio, United States, 43215
        • Research Site
      • Columbus, Ohio, United States, 43210
        • Research Site
      • Marion, Ohio, United States, 43302
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      • Poland, Ohio, United States, 44514
        • Research Site
      • Toledo, Ohio, United States, 43606
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      • Willoughby Hills, Ohio, United States, 44094
        • Research Site
    • Oklahoma
      • Oklahoma City, Oklahoma, United States, 73116
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      • Tulsa, Oklahoma, United States, 74120
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    • Oregon
      • Portland, Oregon, United States, 97213
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      • Portland, Oregon, United States, 97210
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      • Roseburg, Oregon, United States, 97471
        • Research Site
    • Pennsylvania
      • Beaver, Pennsylvania, United States, 15009
        • Research Site
      • Bethlehem, Pennsylvania, United States, 18017
        • Research Site
      • Doylestown, Pennsylvania, United States, 18901
        • Research Site
      • Duncansville, Pennsylvania, United States, 16635
        • Research Site
      • Philadelphia, Pennsylvania, United States, 19140
        • Research Site
      • Philadelphia, Pennsylvania, United States, 19118
        • Research Site
      • Philadelphia, Pennsylvania, United States, 19102
        • Research Site
    • South Carolina
      • Anderson, South Carolina, United States, 29621
        • Research Site
      • Columbia, South Carolina, United States, 29203
        • Research Site
      • Greenville, South Carolina, United States, 29605
        • Research Site
      • Orangeburg, South Carolina, United States, 29118
        • Research Site
    • Tennessee
      • Bristol, Tennessee, United States, 37620
        • Research Site
      • Columbia, Tennessee, United States, 38401
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      • Dyersburg, Tennessee, United States, 38024
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      • Franklin, Tennessee, United States, 37064
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      • Jackson, Tennessee, United States, 38305
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      • Kingsport, Tennessee, United States, 37660
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      • Knoxville, Tennessee, United States, 37923
        • Research Site
      • Memphis, Tennessee, United States, 38163
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    • Texas
      • Arlington, Texas, United States, 76015
        • Research Site
      • Austin, Texas, United States, 78705
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      • Austin, Texas, United States, 78758
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      • Austin, Texas, United States, 78751
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      • Corsicana, Texas, United States, 75110
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      • Dallas, Texas, United States, 75390
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      • Edinburg, Texas, United States, 78539
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      • El Paso, Texas, United States, 79905
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      • Fort Worth, Texas, United States, 76104
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      • Frisco, Texas, United States, 75035
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      • Greenville, Texas, United States, 75402
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      • Houston, Texas, United States, 77030
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      • Houston, Texas, United States, 77074
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      • Houston, Texas, United States, 77004
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      • Houston, Texas, United States, 77054
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      • Houston, Texas, United States, 77099
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      • Houston, Texas, United States, 77008
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      • Houston, Texas, United States, 77057
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      • Houston, Texas, United States, 77036
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      • Houston, Texas, United States, 77031
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      • Lubbock, Texas, United States, 79430
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      • Lufkin, Texas, United States, 75904
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      • McAllen, Texas, United States, 78503
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      • McKinney, Texas, United States, 75069
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      • San Antonio, Texas, United States, 78229
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      • San Antonio, Texas, United States, 78215
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      • San Antonio, Texas, United States, 78205
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      • San Antonio, Texas, United States, 78228
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      • San Antonio, Texas, United States, 78224
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      • Temple, Texas, United States, 76502
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    • Vermont
      • Burlington, Vermont, United States, 05401
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    • Virginia
      • Alexandria, Virginia, United States, 22304
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      • Chesapeake, Virginia, United States, 23320
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      • Fairfax, Virginia, United States, 22030
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      • Fairfax, Virginia, United States, 22033
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      • Hampton, Virginia, United States, 23666
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      • Manassas, Virginia, United States, 20110
        • Research Site
      • Mechanicsville, Virginia, United States, 23116
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      • Norfolk, Virginia, United States, 23502
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      • Richmond, Virginia, United States, 23219
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      • Richmond, Virginia, United States, 23229
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      • Richmond, Virginia, United States, 23298-0160
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    • Washington
      • Silverdale, Washington, United States, 98383
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    • West Virginia
      • Bluefield, West Virginia, United States, 24701
        • Research Site
    • Wisconsin
      • Milwaukee, Wisconsin, United States, 53226
        • Research Site

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Key Inclusion Criteria:

  • Clinical history of advanced CKD not on dialysis with at least 1 historic estimated glomerular filtration rate (eGFR) < 45.0 mL/mi)/1.73 m2 at least 12 weeks prior to screening
  • Not currently receiving dialysis with an eGFR < 45.0 mL/min/1.73m2, per the central laboratory during screening
  • Chronic anemia due to renal failure
  • Two Hb concentrations < 10.0 g/dL, at least 2 weeks apart during screening using the modified Hb point of care (POC) device
  • Iron replete, defined as a transferrin saturation (TSAT) ≥ 20% and a ferritin ≥ 100 ng/mL, per the central laboratory during screening
  • Vitamin B12 and folate replete, defined as a vitamin B12 level > 180 pg/mL and a folate concentration > 7 nmol/L, per the central laboratory during screening
  • Clinically stable in the opinion of the investigator
  • Subject has provided written informed consent

Key Exclusion Criteria:

  • Systemic hematologic disease (eg, sickle cell anemia, myelodysplastic syndrome, hematologic malignancy)
  • Current or prior malignancy within 5 years of screening, with the exception of non-melanoma skin cancers and cervical intraepithelial neoplasia
  • Treatment for any malignancy (eg, radiation, chemotherapy, hormone therapy, or biologics) within 5 years of screening, with the exception of locally excised non-melanoma skin cancer or cervical intraepithelial neoplasia
  • Female subject not willing to use highly effective methods of birth control during treatment and for 4 weeks after the end of treatment
  • Subject is pregnant or breast feeding, or might become pregnant during the study or within 4 weeks after the end of treatment
  • Currently receiving intravenous (IV) antibiotics for treatment of an active infection
  • Known Human Immunodeficiency Virus (HIV) positive
  • Currently receiving systemic immunosuppressive therapy with the exception of prednis(ol)one ≤ 10 mg per day (or the steroid equivalent)
  • History of any organ transplant
  • Currently enrolled in another interventional study (eg, studies which require medical device use or drug therapy or with protocol required procedures), or less than 4 weeks since ending another interventional study(s) or receiving investigational agent(s)
  • Known neutralizing anti-erythropoietic protein antibodies
  • Known sensitivity to any of the products to be administered during dosing
  • Previously enrolled in this study
  • Not expected to be available for protocol required study visits or procedures to the best of the subject and investigator's knowledge
  • Subject has any kind of disorder that, in the opinion of the investigator, may compromise the ability of the subject to give written informed consent and/or comply with all required study procedures
  • Occurrence of stroke or myocardial infarction (MI) within 24 weeks of screening
  • Receipt of RBC transfusion within 8 weeks of screening
  • Occurrence of seizure, clinically relevant active bleeding (eg, gastrointestinal [GI] bleed) or any hospitalization within 8 weeks of screening
  • Receipt of any IV iron therapy within 4 weeks of screening
  • Changes in oral iron therapy within 4 weeks of screening
  • Receipt of ESA therapy within 4 weeks of screening
  • Diagnosis or treatment of malignancy, with the exception of non-melanoma skin cancers and cervical intraepithelial neoplasia during screening
  • Receipt of ESA therapy, RBC transfusions, IV iron therapy during screening
  • Changes in oral iron therapy during screening
  • Occurrence of stroke, MI, seizure, clinically relevant active bleeding (eg, GI bleed), any hospitalization or outpatient surgery during screening
  • Uncontrolled hypertension during screening. Defined in this study, as a mean systolic blood pressure > 140 mmHg at both screening visits, or a mean systolic blood pressure >/= 160 mmHg at any screening visit, or a mean diastolic blood pressure >/= 90 mmHg at any screening visit.
  • Expected or scheduled change in oral iron therapy or receipt of IV iron therapy within 4 weeks after randomization
  • Expected or scheduled receipt of a RBC transfusion within 8 weeks after randomization
  • Expected or scheduled organ transplant within 24 weeks after randomization
  • Expected or scheduled initiation of dialysis within 24 weeks after randomization

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: TREATMENT
  • Allocation: RANDOMIZED
  • Interventional Model: PARALLEL
  • Masking: TRIPLE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
ACTIVE_COMPARATOR: Hb-Based Titration Group
Participants received darbepoetin alfa as a subcutaneous (SC) injection once every 4 weeks (Q4W) for up to 96 weeks. The dose of darbepoetin alfa was titrated based on the Hb concentration on the date of the visit, the corresponding Hb rate of rise (ROR), and the previously assigned dose. Doses were reduced if Hb exceeded 10.5 g/dL or Hb ROR exceeded 1.0 g/dL/4W. When darbepoetin alfa therapy was withheld per the dosing algorithm, placebo was administered. The starting dose of darbepoetin alfa was 0.45 micrograms/kilogram (mcg/kg) and the protocol specified doses ranged from 10 to 300 mcg.
Darbepoetin alfa was presented as single use prefilled syringes (PFS). Investigational product was administered SC Q4W for the duration of the treatment period.
Other Names:
  • Aranesp
Placebo was presented as single use PFS. Participants received a SC placebo injection in place of darbepoetin alfa therapy when the dose of study drug was withheld per the dosing algorithm for the duration of the treatment period.
EXPERIMENTAL: Fixed Dose Group
Participants received darbepoetin alfa as a SC injection Q4W at the same dose as assigned at the time of randomization for the duration of the 96 week treatment period. There was 1 exception to the fixed dose strategy: if the Hb was > 12.0 g/dL, darbepoetin alfa therapy was withheld and placebo administered. Once the Hb fell to < 10.0 g/dL, darbepoetin alfa therapy resumed at the same dose. The starting dose of darbepoetin alfa was 0.45 mcg/kg and the protocol specified doses ranged from 10 to 300 mcg.
Darbepoetin alfa was presented as single use prefilled syringes (PFS). Investigational product was administered SC Q4W for the duration of the treatment period.
Other Names:
  • Aranesp
Placebo was presented as single use PFS. Participants received a SC placebo injection in place of darbepoetin alfa therapy when the dose of study drug was withheld per the dosing algorithm for the duration of the treatment period.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Percentage of Participants in Receipt of 1 or More RBC Transfusions
Time Frame: From randomization until the end of study, up to week 101.
The percentage of participants receiving at least 1 RBC transfusion during the evaluation period was recorded for each treatment group. The evaluation period began from the date of randomization, and participants were censored at the last dose of investigational product plus 3 months or end of study, whichever was earlier (on-treatment approach).
From randomization until the end of study, up to week 101.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Mean Number of Units of RBC Transfused
Time Frame: From randomization until the end of study, up to week 101.
The total number of units of RBC transfused per participant during the evaluation period was recorded for each treatment group. The evaluation period began from the date of randomization, and participants were censored at the last dose of investigational product plus 3 months or end of study, whichever was earlier (on-treatment approach). The mean total number of RBC units transfused per participant is presented.
From randomization until the end of study, up to week 101.
Time to First RBC Transfusion
Time Frame: From randomization until the end of study, up to week 101.
Time to first RBC transfusion during the evaluation period was recorded for each treatment group. The evaluation period began from the date of randomization, and participants were censored at the last dose of investigational product plus 3 months or end of study, whichever was earlier (on-treatment approach). The time to first RBC transfusion is presented using Kaplan-Meier (KM) estimates at 6, 12, 18, and 24 months.
From randomization until the end of study, up to week 101.
Mean Achieved Hb Concentration While Receiving Investigational Product
Time Frame: From week 13 until the end of study, up to week 101.
Average achieved Hb concentration while receiving investigational product was recorded as mean Hb using the area under the curve (AUC) method for each treatment group. The AUC of Hb was calculated according to the trapezoidal method, standardized as daily AUC. Participants with available Hb values from study day 85 (week 13) to the last dose date were included in the calculation.
From week 13 until the end of study, up to week 101.
Geometric Mean Cumulative Dose of Darbepoetin Alfa Per 4 Weeks
Time Frame: From randomization until the end of study, up to week 101.
Cumulative doses of darbepoetin alfa adjusted for investigation product exposure time (e.g. mean cumulative darbepoetin alfa dose per 4 weeks) were calculated for each treatment group using the total cumulative dose during the study divided by total number of weeks dosed then multiplied by 4. The geometric mean cumulative dose is presented.
From randomization until the end of study, up to week 101.

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Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

July 30, 2012

Primary Completion (ACTUAL)

October 19, 2017

Study Completion (ACTUAL)

October 19, 2017

Study Registration Dates

First Submitted

June 7, 2012

First Submitted That Met QC Criteria

July 26, 2012

First Posted (ESTIMATE)

July 30, 2012

Study Record Updates

Last Update Posted (ACTUAL)

September 21, 2022

Last Update Submitted That Met QC Criteria

September 8, 2022

Last Verified

September 1, 2022

More Information

Terms related to this study

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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