AMPK-activation by Metformin in FSGS: AMP-FSGS (AMP-FSGS)

The primary objective of this study is to determine whether extended-release MF (in addition to standard of care (S-o-C)) is superior to placebo in reducing podocyte injury and promoting podocyte survival by 6-months in Focal Segmental Glomerulosclerosis (FSGS).

Study Overview

• Status: Recruiting
• Conditions: Focal Segmental Glomerulosclerosis
• Intervention / Treatment: Drug: Metformin + Standard of Care; Other: Placebo + Standard of Care

Detailed Description

Focal Segmental glomerulosclerosis (FSGS) is currently the most common primary glomerular disease that progresses to ESKD in the US. FSGS is typified by significant proteinuria, and by disorganization of the actin cytoskeleton of highly specialized epithelial cells which support the glomerular capillary loop called podocytes. Podocytes are characterized by foot processes, whose disorganization with injury is visualized on electron microscopy as foot process effacement (FPE). Podocytes are also incapable of self-renewal, and podocyte loss over ~40% per glomerulus leads to proteinuria, the nephrotic syndrome (NS) and FSGS. Such critical podocyte loss alone is sufficient for progressive CKD and ESKD. Currently, the reported rate of complete and/or partial response is 40-70% in various series with a rate of progression to ESKD 30-53% in 5-10 years.

Distinct from FSGS, Minimal Change Disease (MCD), which despite showing similar diffuse FPE and NS, has preserved podocyte numbers and rare progression to ESKD (5-20% in 20 years). MCD can be morphologically indistinguishable from early FSGS, and some MCD cases reportedly transition to FSGS. Hence, identifying and targeting mechanisms in MCD that specifically promote survival of injured podocytes with FPE, could help switch an FSGS phenotype to an "MCD-like" phenotype, and prevent or retard progression of FSGS. Currently, therapeutics in FSGS focus on immune modulation, or on hemodynamic interventions used in generically all cases of NS. Specific strategies to directly promote podocyte survival and limit podocytopenia to within the critical threshold during injury, have not been pursued clinically. Hence, many FSGS cases will progress to ESKD or encounter dose limiting side-effects of immune therapies (corticosteroids, or other agents), representing a significant therapeutic gap in the field.

In this context, MF is an Ampk-activator that is widely used, demonstrably safe, and inexpensive with reported renal benefit in diabetic and non-diabetic CKD. Its specific utility to promote cell survival of injured podocytes in FSGS has never been tested. Our preclinical data shows that an "MCD-like" pathology with podocyte injury/FPE transitioned to podocytopenia and FSGS by AMPK inhibition, while AMPK activation with MF mitigated podocytopenia in FSGS models.

The purpose of this study is to test whether Metformin use in individuals with FSGS as an adjunct to standard -of-care (corticosteroids, anti RAAS measures, BP control) is safe and will activate kidney cell AMPK and reduce podocyte injury. The primary objective is to determine whether extended-release MF (in addition to standard of care (S-o-C)) is superior to placebo in reducing podocyte injury and promoting podocyte survival by 6-months in Focal Segmental Glomerulosclerosis (FSGS). Specifically, for this purpose, this study will primarily evaluate sequential urinary podocyte mRNA excretion to identify individual urinary mRNA trajectories representing podocyte injury/depletion and potential prognostic signals in the MF study limb vs control.

A secondary objective of this study is to use multiple blood, urine and biopsy assays to test whether the addition of Metformin ( to S-o-C) mitigates kidney disease progression parameters superior to placebo. These assays will include large scale urine and serum protein profiling, protein and RNA tests performed in kidney biopsies.

Another secondary objective of this study is to test whether the addition of Metformin ( to S-o-C) is safe in patients with proteinuria and FSGS. This will be accomplished by specific questionnaires and blood tests geared towards MF-associated adverse effects.

Results of this study will inform a larger, phase 2/3 randomized trial which will evaluate the efficacy of MF treatment versus placebo in attenuating proteinuria and kidney function decline in FSGS.

• Study Type: Interventional
• Enrollment (Estimated): 30
• Phase: Phase 2; Phase 1

Contacts and Locations

• Study Contact: Name: Madhav C Menon, MD; Phone Number: 20373734507; Email: madhav.menon@yale.edu

Study Locations

• United States
  • Connecticut
    • New Haven, Connecticut, United States, 06510
      • Recruiting
      • Yale New Haven Hospital
      • Contact: Madhav Menon; Email: madhav.menon@yale.edu
      • Sub-Investigator: Francis P Wilson, MD
      • Sub-Investigator: Randy Luciano, MD PhD
  • New York
    • New York, New York, United States, 10029
      • Recruiting
      • Mount Sinai Hospital
      • Contact: Cijiang He; Email: cijiang.he@mssm.edu
      • Sub-Investigator: Joji Tokita
      • Sub-Investigator: Kristin Meliambro
      • Sub-Investigator: Jia Fu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Provision of signed and dated informed consent form
2. Stated willingness to comply with all study procedures and availability for the duration of the study
3. Male or female, aged greater than or equal to 18 years, but </= 80 years age at the time of signing the informed consent
4. Biopsy-confirmed primary FSGS as defined by expert renal pathology at either institutions. For homogeneity of diagnoses, demonstrable segmental or global sclerosis lesions (>/=1 glomerulus) with diffuse podocyte foot process effacement by electron microscopy (>/+ 50% of examined glomerular tufts), or show evidence of mesangial expansion or mesangial sclerosis, also confirmed by electron microscopy.
5. Therapeutic plan by treating physician for immunomodulatory treatment using Glucocorticoids.
6. Ability to take oral medication and be willing to adhere to the MF or Placebo regimen
7. For females of reproductive potential: use of highly effective contraception for at least 1 month prior to screening and agreement to use such a method during study participation and for an additional 12 weeks after the end of VPA administration. For males of reproductive potential: use of condoms or other methods to ensure effective contraception with partner.

Exclusion Criteria:

1. Liver disease: confirmed cirrhosis liver (any stage), acute hepatitis (> 2 fold increase in liver enzymes, any coagulopathy, hyperbilirubinemia, ascites or encephalopathy)
2. estimated GFR < 32 ml/min
3. Diabetes Mellitus diagnosis at the time of biopsy or need for oral hypoglycemic agents/Insulin, or taking Metformin for other indications
4. Treatment with another investigational drug or other intervention within 3 months
5. Current pregnancy or desire to become pregnant during the study period
6. Unwilling to use two forms of birth control (for women of childbearing age)
7. Under hospice care
8. Confirmed Dementia diagnoses in EMR problem list
9. Incarceration
10. Homelessness
11. Inability to consent
12. Currently enrolled in (or completed within the past 30 days) a study of an investigational drug or device.
13. Life expectancy of less than 6 months as determined by the clinical judgement of the patient's primary physician
14. Allergy or sensitivity to Metformin
15. Platelet count < 100,000/µL; INR > 1.5; Bleeding diathesis or blood thinner use contraindicating biopsy.
16. Bleeding diathesis or blood thinner use contraindicating biopsy will be excluded entirely from participation in research biopsy portion of study only, even if anticoagulation/blood thinners can be held temporarily.
17. Simultaneous use of Carbonic anhydrase inhibitor agents
18. Use of systemic immunosuppressive medication for non-renal indications

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Metformin + Standard of Care; Administration of daily oral extended-release Metformin 500 mg tablets with standard of care for 6 months.	Drug: Metformin + Standard of Care; Administration of daily oral extended-release Metformin 500 mg tablets with standard of care for 6 months.
Placebo Comparator: Placebo + Standard of Care; Administration of daily placebo tablets with standard of care for 6 months.	Other: Placebo + Standard of Care; Administration of daily placebo tablets with standard of care for 6 months.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Slope of urinary NPHS2:Creatinine ratio	Measure of podocinuria via evaluation of urine podocin mRNA(nphs2) (measured as number of molecules detected by qPCR in the collected urine pellet) over the creatinine concentration. Intended for evaluation of efficacy of metformin versus placebo.	6 months following randomization

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
estimated Glomerular Filtration Rate (eGFR)	Calculated from serum creatinine (mg/dl) using the CKD-EPI formula. Intended for evaluation of efficacy of metformin versus placebo.	6 months post-randomization
Slope of eGFR	Change in eGFR from randomization to 6 months by incorporating eGFR at all timepoints in study between baseline and 6 months post-randomization. eGFR calculated from serum creatinine (mg/dl) using the CKD-EPI formula. Intended for evaluation of efficacy of metformin versus placebo.	6 months post-randomization
Urine protein:creatinine ratio	Calculated ratio of urine protein and creatinine, each collected from the electronic medical record. Intended for evaluation of clinical efficacy of metformin versus placebo.	6 months post-randomization
Slope of urine protein:creatinine ratio	Change in urine protein:creatinine ratio from randomization to 6 months by incorporating urine protein:creatinine ratio at all timepoints in study between baseline and 6 months post-randomization. Intended for evaluation of clinical efficacy of metformin versus placebo.	6 months post-randomization
Complete remission	Calculated as the number of patients in complete remission, defined as <0.5 gm urine protein excretion over 24 hours, or urine protein creatinine ratio < 0.5 at 6 months post-randomization. Intended for evaluation of clinical efficacy of metformin versus placebo.	6 months post-randomization
Complete or partial remission	Calculated as the number of patients with complete remission (defined as <0.5 gm urine protein excretion over 24 hours, or urine protein creatinine ratio < 0.5) or partial remission (>50% reduction in proteinuria from pre-randomization). Intended for evaluation of clinical efficacy of metformin versus placebo.	6 months post-randomization
Discontinuation of study drug	Number of patients who discontinued study drug for any reason within 6 months of randomization. Intended for evaluation of patient compliance of metformin use.	Within 6 months post-randomization
Modified Kidney Disease Quality of Life (KDQOL) score	Calculated as the mean (standard deviation) of all total scores. Total scores are calculated by combining scores of 8 subsections of the KDQOL, and range from 0 - 163, with higher scores representing better quality of life. Intended for evaluation of adverse effects of metformin versus placebo.	1 month post-randomization
Modified Kidney Disease Quality of Life (KDQOL) score	Calculated as the mean (standard deviation) of all total scores. Total scores are calculated by combining scores of 8 subsections of the KDQOL, and range from 0 - 163, with higher scores representing better quality of life. Intended for evaluation of adverse effects of metformin versus placebo.	6 months post-randomization
Hypoglycemia symptom scores	Calculated as the mean (standard deviation) of all total scores. Total scores are calculated by combining scores of 6 subsections of the questionnaire, and range from 0 - 18, with higher scores representing greater symptoms. Intended for evaluation of adverse effects of metformin versus placebo.	6 months post-randomization
Gastrointenstinal symptom scores	Calculated as the mean (standard deviation) of all total scores. Total scores are calculated by combining scores of 15 subsections of the questionnaire, and range from 0 - 105, with higher scores representing greater symptoms. Intended for evaluation of adverse effects of metformin versus placebo.	1 month post-randomization
Gastrointenstinal symptom scores	Calculated as the mean (standard deviation) of all total scores. Total scores are calculated by combining scores of 15 subsections of the questionnaire, and range from 0 - 105, with higher scores representing greater symptoms. Intended for evaluation of adverse effects of metformin versus placebo.	6 months post-randomization
Kidney biopsy fibrosis scores	Evaluation of kidney fibrosis as measured by quantification of Masson's Trichrome staining under microscopy of biopsy at 6 months post-randomization. Scores will be grouped by the following: <10%, 10-25%, 25-50%, > 50%. Intended for evaluation of clinical efficacy of metformin versus placebo.	6 months post-randomization
Number of patients with Lactate levels>2.5	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Lactate levels>5	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Vitamin B12 levels <lower limit of Normal	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with serum glutamic-oxaloacetic transaminase (SGOT) >2 fold increase	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Serum Glutamic Pyruvic Transaminase (SGPT) >2 fold increase	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Serum amyloid P component (SAP) >2 fold increase	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Bililirubin-Total >2	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Bilirubin indirect >1	As determined from the electronic medical record. Intended for evaluation of adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with hemoglobin (Hb) <9	As determined from the electronic medical record. Intended for evaluation of disease progression and adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with hematocrit (Hct) <27	As determined from the electronic medical record. Intended for evaluation of disease progression and adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with mean corpuscular volume (MCV) >100	As determined from the electronic medical record. Intended for evaluation of disease progression and adverse effects of metformin versus placebo.	Within 6 months post-randomization
Number of patients with Total White Blood Cells (WBC) <1500	As determined from the electronic medical record. Intended for evaluation of disease progression and adverse effects of metformin versus placebo.	Within 6 months post-randomization
Slope of Urine Nphs2	Change in urine podocin mRNA(Nphs2), measured as number of molecules detected by qPCR in the collected urine pellet over the creatinine concentration. Slope measured by incorporating nphs2 measurements at all timepoints in study between baseline and 6 months post-randomization. Intended for evaluation of efficacy of metformin versus placebo.	6 months post-randomization
Slope of Urine Aqp2	Change in urine Aquaporin-2 mRNA(Aqp2), measured as number of molecules detected by qPCR in the collected urine pellet over the creatinine concentration. Slope measured by incorporating Aqp2 measurements at all timepoints in study between baseline and 6 months post-randomization. Intended for evaluation of efficacy of metformin versus placebo.	6 months post-randomization
Slope of Urine Tgfb1	Change in urine transforming growth factor-beta1 mRNA (Tgfb1), measured as number of molecules detected by qPCR in the collected urine pellet over the creatinine concentration. Slope measured by incorporating Tgfb1 measurements at all timepoints in study between baseline and 6 months post-randomization. Intended for evaluation of efficacy of metformin versus placebo.	6 months post-randomization

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Body Mass Index (BMI)	Measured in kg/m2. Exploratory outcome intended for evaluation of adverse effects of metformin versus placebo.	3 months post-randomization
Body Mass Index (BMI)	Measured in kg/m2. Exploratory outcome intended for evaluation of adverse effects of metformin versus placebo.	6 months post-randomization

Collaborators and Investigators

• Sponsor: Yale University
• Collaborators: United States Department of Defense
• Investigators: Principal Investigator: Madhav Menon, MD, Yale University; Principal Investigator: Cijiang He, Icahn School of Medicine at Mount Sinai

Study record dates

Study Major Dates

• Study Start (Actual): December 14, 2023
• Primary Completion (Estimated): November 1, 2027
• Study Completion (Estimated): November 1, 2027

Study Registration Dates

• First Submitted: October 13, 2023
• First Submitted That Met QC Criteria: October 13, 2023
• First Posted (Actual): October 19, 2023

Study Record Updates

• Last Update Posted (Actual): February 3, 2026
• Last Update Submitted That Met QC Criteria: January 30, 2026
• Last Verified: January 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Urogenital Diseases; Male Urogenital Diseases; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Glomerulonephritis; Nephritis; Glomerulosclerosis, Focal Segmental; Health Services Administration; Health Care Quality, Access, and Evaluation; Organic Chemicals; Quality of Health Care; Quality Indicators, Health Care; Biguanides; Guanidines; Amidines; Metformin; Standard of Care
• Other Study ID Numbers: 2000035723; HT9425-23-1-0454 (Other Grant/Funding Number: Department of the Army)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No