TW202423479A - Dosage and administration of anti-c5 antibodies for preventing or minimizing cardiac surgery associated acute kidney injury (csa-aki) and/or subsequent major adverse kidney events (make) in patients with chronic kidney disease - Google Patents

Abstract

Provided herein are methods of preparing a human patient for surgery (e.g., cardiac surgery with cardiopulmonary bypass (CPB)) in a particular sub-population (e.g., a human patient with kidney disease, including chronic kidney disease (CKD)), methods of inhibiting terminal complement activation in the human patient, methods of treating a human patient with CKD prior to cardiac surgery with CPB, methods of preventing or reducing cardiac surgery associated acute kidney injury (CSA-AKI) in a human patient with CKD, and methods of preventing or reducing one or more MAKE in a human patient with CKD. The methods comprise administering to the patient an anti-C5 antibody, e.g., ravulizumab or eculizumab, or antigen binding fragments thereof, according to a particular clinical dosage regimen and according to a specific schedule.

Description

Dosing and administration of anti-C5 antibodies for preventing or minimizing cardiac surgery-associated acute kidney injury (CSA-AKI) and/or subsequent major adverse renal events (MAKE) in patients with chronic kidney disease

Cross-references to related applications

This application claims priority to and the benefit of U.S. Provisional Application No. 63/410,753 (filed on September 28, 2022) and U.S. Provisional Application No. 63/440,968 (filed on January 25, 2023), the entire contents of which are incorporated herein by reference.

The presence of chronic kidney disease (CKD) in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) carries a high risk of adverse outcomes, and these risks are further enhanced by postoperative acute renal injury (AKI) (see, e.g., Meersch M et al., Current Opinion in Anaesthesiology . 2016;29(3):413-420; Mehta RH et al., Circulation. 2006;114(21):2208-2216; Nashef SA et al., EuroSCORE II. Eur J Cardiothorac Surg. 2012;41(4):734-744; Thakar CV et al., Kidney J Surg. 2013;41(5):735-744; Int. Kidney International 2005;67(3):1112-1119; and Thakar CV et al., J. Am. Soc. Nephrol . 2005;16(1):162-168). Post-CPB AKI is characterized by a sudden deterioration in renal excretory function after cardiac surgery, usually manifested by a decrease in glomerular filtration rate (GFR). AKI occurs in approximately 25% of patients after CPB (see, e.g., Corredor C et al., J. Cardiothorac. Vasc. Anesth . 2016;30(1):69-75; and Hu J et al., J. Cardiothorac. Vasc . Anesth . 2016;30(1):82-89) and in up to 60% to 80% of patients with moderate to severe CKD (calculated according to Priyanka P et al., J. Thorac. Cardiovasc. Surg . 2021;162(1):143-151.e147).

Post-CPB AKI is associated with in-hospital mortality, need for renal replacement therapy (KRT; also called renal replacement therapy or RRT), permanent loss of renal function (risk of progression to CKD, including progression to end-stage renal disease), high resource utilization, and poor long-term survival (see, e.g., Peng et al., Anesth. Analg. 2022 Oct 1;135(4):744-756; Chawla LS et al., N. Engl. J. Med. 2014;371(1):58-66; Chawla LS et al., Kidney Int. 2011;79(12):1361-1369; Coca SG et al., Am. J. Kidney Dis. Am J Nephrol 2009;53(6):961-973; Dasta JF et al, Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association ; 2008;23(6): 1970-1974; Ishani A et al, J. Am. Soc. Nephrol . 2009;20(1):223-228; Mangano CM et al, The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med. 1998;128(3):194-203; Thakar CV et al., Incidence and outcomes of acute kidney injury in intensive care units: a Veterans Administration study. Crit Care Med. 2009;37(9):2552-2558). A large meta-analysis showed that in-hospital mortality after cardiac surgery was 1.7% and 10.7% for patients without AKI and those with AKI, respectively. Long-term (1-5 years) mortality was 11.9% and 30%, respectively (Hu, 2016). Persistent renal dysfunction (SKD) after AKI increases the risk of short- and long-term mortality many-fold compared with transient AKI or no AKI (see, e.g., Brown JR et al., Ann. Thorac. Surg . 2010;90(4):1142-1148; Corredor C et al., J. Cardiothorac. Vasc. Anesth. 2016;30(1):69-75; Swaminathan M et al., Ann. Thorac. Surg. 2010;89(4):1098-1104) and increases the risk of new-onset CKD or accelerates the progression of pre-existing CKD (see, e.g., Chawla LS et al., N. Engl. J. Med. 2014;371(1):58-66; Chawla LS et al., Kidney Int. 2011;79(12):1361-1369; and Kellum JA et al. , Nat. Rev. Dis. Primers . 2021;7(1):52). The risk of developing end-stage renal disease after AKI is significantly greater in patients with preexisting CKD (see, e.g., Ishani A et al., J. Am. Soc. Nephrol. 2009;20(1):223-228.2009 and Wu VC et al., Kidney Int. 2011;80(11):1222-1230).

The need for KRT due to AKI after CPB occurs in approximately 2% of patients undergoing cardiac surgery (see, e.g., Hu J et al., J. Cardiothorac. Vasc. Anesth . 2016;30(1):82-89), but appears to be increased in those with underlying CKD, reaching 13.3% in severe CKD (see, e.g., Chawla LS et al., J. Am. Soc. Nephrol. 2012;23(8):1389-1397; Mehta RH et al., Circulation. 2006;114(21):2208-2216; Thakar CV et al., Kidney Int . 2005;67(3):1112-1119; Thakar CV et al., J. Am. Soc. Nephrol. 2005;16(1):162-168). In-hospital mortality is extremely high, ranging from 33% to >50% (see, e.g., Chawla LS et al., J. Am. Soc . Nephrol. 2012 ;23(8):1389-1397; Dasta JF et al ., Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association. 2008;23(6):1970-1974; Landoni G et al. , European Journal of Anaesthesiology . 2006;23(1):17-22; and Thakar CV et al., Kidney Int . [Nephrology International] 2005;67(3):1112-1119; Thakar CV et al., J. Am. Soc. Nephrol. [American Society of Nephrology] 2005;16(1):162-168).

Multiple treatment approaches have failed to reduce AKI after CPB or reduce the adverse clinical outcomes associated with AKI (i.e., SKD at risk for progressive CKD), the need for KRT, and mortality (see, e.g., Schurle A et al., J. Clin. Med . 2021;10(24)). There remains a high unmet medical need to develop treatments that reduce the risk of AKI and its consequences in patients with CKD undergoing cardiac surgery with CPB. Therefore, an object of the present disclosure is to provide improved methods for preventing and/or minimizing cardiac surgery-associated renal injury (CSA-AKI) and/or subsequent major adverse renal events (MAKE) in patients with CKD.

The present disclosure relates to compositions and methods for preventing and/or treating acute renal injury (AKI) in human patients with chronic kidney disease (CKD) who are undergoing cardiopulmonary bypass (CPB). The methods of the present invention improve upon existing treatment modalities, such as intraoperative and postoperative strategies, which provide and target inflammatory mediators of AKI in an inpatient setting. In contrast to common approaches for reducing AKI, the compositions and methods of the present disclosure can be administered in an outpatient setting and effectively prevent AKI and significantly improve clinical outcomes, such as reducing major adverse events and even death in patients with unmet needs.

Provided herein are methods involving preparing human patients for surgery (e.g., cardiopulmonary bypass (CPB) heart surgery) in a specific subpopulation (e.g., human patients with kidney disease, including chronic kidney disease (CKD)), comprising administering to the patient an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered (or for administration) according to a specific clinical dosing regimen (e.g., in a single dose based on body weight) and according to a specific schedule (e.g., at least one to seven calendar days before surgery).

Additionally, provided herein are methods of inhibiting terminal complement activation in human patients, methods of treating human patients with CKD prior to CPB cardiac surgery, methods of preventing or reducing (e.g., minimizing) cardiac surgery associated acute kidney injury (CSA-AKI) in human patients with CKD, and methods of preventing or reducing (e.g., minimizing) one or more major adverse renal events (MAKE) in human patients with CKD.

Any suitable anti-C5 antibody or antigen-binding fragment thereof may be used in the methods described herein. Exemplary anti-C5 antibodies are ravulizumab (ULTOMIRIS®) or antigen-binding fragments and variants thereof comprising heavy and light chains having the sequences set forth in SEQ ID NOs: 14 and 11, respectively. In other embodiments, the antibody comprises heavy and light chain complementation determining regions (CDRs) or variable regions (VRs) of ravulizumab. Thus, in one embodiment, the antibody comprises CDR1, CDR2, and CDR3 domains of a heavy chain variable (VH) region of ravulizumab having the sequence set forth in SEQ ID NO: 12, and CDR1, CDR2, and CDR3 domains of a light chain variable (VL) region of ravulizumab having the sequence set forth in SEQ ID NO: 8. In another embodiment, the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having amino acid sequences as shown in SEQ ID NOs: 12 and 8, respectively. In another embodiment, the antibody comprises a heavy chain constant region as shown in SEQ ID NO: 13.

In another embodiment, the antibody comprises a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met429Leu and Asn435Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each numbered according to the EU numbering convention.

In another embodiment, the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively; and a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met429Leu and Asn435Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each numbered according to the EU numbering convention.

In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the BNJ421 antibody (described in WO 2015134894 and U.S. Patent No. 9,079,949). In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the 7086 antibody (see U.S. Patent Nos. 8,241,628 and 8,883,158). In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the 8110 antibody (see U.S. Patent Nos. 8,241,628 and 8,883,158). In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the 305LO5 antibody (see U.S. Patent No. 9,765,135). In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the anti-C5 antibody comprises the heavy chain and light chain CDRs or variable regions of the REGN3918 antibody.

In another embodiment, the anti-C5 antibody is a biosimilar of eculizumab (SOLIRIS®). For example, in one embodiment, the anti-C5 antibody is, for example, ABP 959 antibody (manufactured by Amgen Inc., USA), ELIZARIA® (manufactured by Generium JNC, Russia), SB12 (manufactured by Samsung Bioepis, Incheon, South Korea), ISU305 (eculizumab biosimilar from ISU Abxis, South Korea), ABLYZE® (eculizumab biosimilar from CinnaGen, Iran), BCD 148 (manufactured by Biocad Medical, Quebec, Canada), Medical, Quebec, Canada), tesidolumab (made by Novartis), crovalimab (made by Roche), CAN106 (made by CanBridge Pharmaceuticals, China), or pozelimab (made by Regeneron).

In another embodiment, the antibody competes for binding to the same epitope on C5 and/or binds to the same epitope on C5 as any of the above antibodies. In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity with any of the above antibodies (e.g., at least about 90%, 95% or 99% variable region identity with SEQ ID NO: 12 or SEQ ID NO: 8).

In another embodiment, the antibody binds human C5 at pH 7.4 and 25°C with a _KD in the range of 0.1 nM ≤ affinity dissociation constant ( _KD ) ≤ 1 nM. In another embodiment, the antibody binds human C5 at pH 7.4 and 25°C with an affinity dissociation constant ( _KD ) of about 0.5 nM. In another embodiment, the antibody binds human C5 at pH 6.0 and 25°C with a _KD of ≥ 10 nM. In another embodiment, the antibody binds human C5 at pH 6.0 and 25°C with a _KD of about 22 nM. In yet another embodiment, the antibody has [( _KD of the antibody or antigen-binding fragment thereof for human C5 at pH 6.0 and 25°C)/( _KD of the antibody or antigen-binding fragment thereof for human C5 at pH 7.4 and 25°C)] greater than 25.

The methods described herein can be used for any type of heart surgery. In another embodiment, the heart surgery is coronary artery bypass graft (CABG). In another embodiment, the surgery is valve replacement or repair. In another embodiment, the surgery is the insertion of a pacemaker or implantable cardioverter defibrillator (ICD). In another embodiment, the surgery is a maze surgery. In another embodiment, the surgery is a heart transplant. In another embodiment, the surgery is the insertion of a ventricular assist device (VAD). In another embodiment, the surgery is the insertion of a total artificial heart (TAH). In another embodiment, the surgery is the insertion of a transcatheter structural heart surgery. In a specific embodiment, the surgery is CPB heart surgery.

In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient at least one calendar day prior to surgery (e.g., CPB heart surgery). In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered one to seven calendar days prior to surgery. For example, in one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered one, two, three, four, five, six, or seven calendar days prior to surgery.

According to the methods described herein, an anti-C5 antibody or an antigen-binding fragment thereof is administered to a patient in a dose based on body weight (e.g., a single dose based on body weight before surgery). In one embodiment, the anti-C5 antibody or an antigen-binding fragment thereof is administered to a patient weighing ≥ 30 to < 40 kg at a dose of 2700 mg. In another embodiment, the anti-C5 antibody or an antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg at a dose of 3000 mg. In another embodiment, the anti-C5 antibody or an antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg at a dose of 3300 mg. In another embodiment, the anti-C5 antibody or an antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg at a dose of 3600 mg.

In one aspect, a method is provided for preparing a human patient (e.g., a human patient with kidney disease, including CKD) for surgery (e.g., CPB heart surgery), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery.

In one embodiment, a method for preparing a human patient with CKD for CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises a CDR1, CDR2 and CDR3 heavy chain sequence as shown in SEQ ID NOs: 19, 18 and 3, respectively, and a CDR1, CDR2 and CDR3 light chain sequence as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)  For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or d)  For patients with a body weight of ≥ For a 100 kg patient, 3600 mg.

In another aspect, a method is provided for inhibiting terminal complement activation in a human patient (e.g., a human patient with kidney disease, including CKD) prior to surgery (e.g., CPB heart surgery), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In one embodiment, a method for inhibiting terminal complement activation in a human patient with CKD before CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d) For patients weighing ≥ 100 kg, 3600 mg.

In some embodiments, according to the methods described herein, terminal complement activation is inhibited in a human patient as assessed by any suitable assay. In one embodiment, the method inhibits terminal complement activation in a human patient by, e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%.

In another aspect, a method is provided for treating a human patient with a kidney disease (e.g., CKD) prior to cardiac surgery (e.g., using CPB), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In one embodiment, a method for treating a human patient with CKD before CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d) For patients weighing ≥ 100 kg, 3600 mg.

In another aspect, a method for preventing or reducing (e.g., minimizing) CSA-AKI in a human patient with a kidney disease (e.g., CKD), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises the CDR1, CDR2, and CDR3 heavy chain sequences shown in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences shown in SEQ ID NOs: 4, 5, and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB).

In one embodiment, a method for preventing or reducing (e.g., minimizing) CSA-AKI in a human patient with CKD is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB) at the following doses: a)   For patients weighing ≥ 30 to < 40 kg, 2700 mg; b)  For patients weighing ≥ 40 to < 60 kg, 3000 mg; c)   For patients weighing ≥ 60 to < 100 kg, 3300 mg; or d)  For patients weighing ≥ 100 kg, 3600 mg.

In another aspect, a method for preventing or reducing (e.g., minimizing) one or more MAKEs in a human patient suffering from a kidney disease (e.g., CKD), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB).

In one embodiment, a method for preventing or reducing (e.g., minimizing) one or more MAKEs in a human patient with CKD is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB) at the following doses: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)  For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or d)  For patients weighing ≥ 100 kg, 3600 mg.

In certain embodiments, the methods described herein provide an optimal desired response (e.g., inhibition of terminal complement activation) in a human patient (e.g., a human patient with a kidney disease, including CKD) prior to surgery (e.g., heart surgery with CPB), prevent or reduce CSA-AKI in a human patient with a kidney disease (e.g., CKD) undergoing surgery (e.g., heart surgery with CPB), and/or prevent or reduce MAKE in a human patient with a kidney disease (e.g., CKD) undergoing surgery (e.g., heart surgery with CPB).

In certain embodiments, the methods described herein are sufficient to maintain a specific serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof. In one embodiment, for example, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 186, 187, 188, 189, 190, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215 80, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 35 5, 360, 365, 37 0, 375, 380, 385, 390, 395, 400, 405, 410, 415, 420, 425, 430, 435, 440, 445, 450, 455, 460, 465, 470, 475, 480, 485, 490, 495, 500, 505, 510, 515, 520 ,525,530,53 5, 540, 545, 550, 555, 560, 565, 570, 575, 580, 585, 590, 595, 600, 605, 610, 615, 620, 625, 630, 635, 640, 645, 650, 655, 660, 665, 670, 675, 680, 685, 690, 695, 700 µg/mL or higher. In one embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at 100 µg/mL or more, 150 µg/mL or more, 200 µg/mL or more, 250 µg/mL or more, 300 µg/mL or more, 350 µg/mL or more, 400 µg/mL or more, or 450 µg/mL or more. In another embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at between 100 µg/mL and 700 µg/mL, preferably between 300 µg/mL and 600 µg/mL. In another embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at about 475 µg/mL. In another embodiment, the method maintains a peak serum concentration of the anti-C5 antibody or antigen-binding fragment thereof at less than about 1800, 1780, 1760, 1740, 1720, 1700, 1680, 1660, 1640, 1620, 1600, 1580, 1560, 1540, 1520, 1500, 1480, 1460, 1440 In some embodiments, the method maintains the peak serum concentration of the anti-C5 antibody or antigen-binding fragment thereof between 900 μg/mL and 1800 μg/mL, preferably between 1050 μg/mL and 1550 μg/mL. In another embodiment, the method maintains a peak serum concentration of the anti-C5 antibody or antigen-binding fragment thereof at about 1350 μg/mL.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and at a frequency to maintain at least 50 µg, 55 µg, 60 µg, 65 µg, 70 µg, 75 µg, 80 µg, 85 µg, 90 µg, 95 µg, 100 µg, 105 µg, 110 µg, 115 µg, 120 µg, 125 µg, 130 µg, 135 µg, 140 µg, 145 µg, 150 µg, 155 µg, 160 µg, 165 µg, 170 µg, 175 µg, 180 µg, 185 µg, 190 µg, 195 µg, 200 µg, 205 µg, 210 µg, 215 µg, 220 µg, 225 µg, 230 µg, 235 µg, 240 µg, 245 µg, 250 µg, 255 µg, 260 µg, 270 µg, 280 µg, 290 µg, 300 µg, 320 µg, 340 µg, 360 µg, 380 µg, 400 µg, 420 µg, 440 µg, 460 µg, 480 µg, 500 µg, 550 µg, 600 µg, 650 µg, 700 µg, 750 µg, 800 µg, 850 µg, 900 µg, 950 µg, 1000 µg, 1050 µg, 1100 µg, 1150 µg, 1200 µg, 1250 µg, 1300 µg, 1350 µg, 1400 µg, 1450 µg, 1500 µg, 1550 µg, 1600 µg, 1650 µg, 1700 µg, 1750 µg or more, for example 1800 µg antibody/mL patient blood.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and frequency that maintains a minimal free C5 concentration. In one embodiment, for example, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and frequency that maintains a free C5 concentration of 0.5 μg/mL or less (e.g., 0.4 μg/mL, 0.3 μg/mL, 0.2 μg/mL, or 0.1 μg/mL or less).

The anti-C5 antibody or antigen-binding fragment thereof can be administered to a patient by any suitable method. In one embodiment, the antibody is formulated for intravenous administration.

The efficacy of the methods provided herein can be assessed using any suitable means. In one embodiment, a single preoperative weight-based dose of an anti-C5 antibody or antigen-binding fragment thereof results in complete C5 inhibition for at least 18 days.

In another embodiment, the method prevents the need for renal replacement therapy (KRT).

In another embodiment, the method prevents or reduces CSA-AKI in a human patient with CKD. In one embodiment, CSA-AKI is characterized by: a)   Increase in serum creatinine (sCr) or serum cystin C (sCysC) by ≥ 0.3 mg/dL in a 48-hour period within 7 days after CPB and/or b)  Increase in sCr or sCysC by ≥ 1.5 times baseline within 7 days after CPB or at 15, 30, 60, or 90 days after CPB.

In another embodiment, after treatment, the human patient does not have severe CSA-AKI (stage 2 or 3) as assessed by modified Kidney Disease Improving Global Outcomes (KDIGO) criteria based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB.

In another embodiment, after treatment, the human patient does not have severe CSA-AKI as assessed by the modified Risk, Injury, Failure, Renal Function Loss, and End-Stage Kidney Disease (RIFLE) criteria based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB.

In another embodiment, the method results in complete recovery of CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the complete recovery is characterized by sCr < 1.1 times baseline.

In another embodiment, the method results in partial recovery of CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the partial recovery is characterized by sCr ≥ 1.1 - < 1.5 times baseline.

In another embodiment, the method results in improvement in CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the improvement is characterized by sCr ≥1.5 - <2.0 times baseline.

In another embodiment, the method results in stable CSA-AKI characterized by sCr ≥2.0 - <3.0 times baseline within 7, 30, 45, 60, or 90 days after surgery.

In another embodiment, the method prevents or reduces one or more MAKEs in a human patient with CKD. In one embodiment, the one or more MAKEs are persistent renal dysfunction (SKD), defined, for example, as an estimated glomerular filtration rate (eGFR) after CPB that is > 25% lower than baseline, wherein the reduction in eGFR is determined by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula based on serum cystin C (sCysC) or serum creatinine (sCr). In another embodiment, the one or more MAKEs are the occurrence of renal replacement therapy (KRT) after CPB. In another embodiment, the one or more MAKEs are death from any cause after CPB.

In another embodiment, the method results in a change from baseline in quality of life as assessed by a quality of life assessment. For example, in one embodiment, the quality of life assessment is the Kidney Disease Quality of Life Tool (KDQOL-36). In another embodiment, the quality of life assessment is the European Quality of Life Group 5 Dimensions 5 Levels (EQ-5D-5L). In another embodiment, the quality of life assessment is the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Scale.

In another embodiment, the method causes a biomarker associated with vascular inflammation (e.g., abscess tumor necrosis factor receptor 1 [TNF-R1 or sTNF-R1]) to change to normal levels. In another embodiment, the method causes a biomarker associated with endothelial damage and/or activation (e.g., thrombomodulin) to change to normal levels. In another embodiment, the method causes a biomarker associated with renal damage (e.g., neutrophil gelatin associated lipocalin [NGAL]) to change to normal levels. In another embodiment, the method causes a biomarker associated with cell cycle arrest inducer (e.g., tissue metalloproteinase inhibitor-2 [TIMP-2]) to change to normal levels. In another embodiment, the method results in a shift toward normal levels of complement proteins and complement activation pathway products (e.g., soluble C5b-9).

Also provided are kits comprising a pharmaceutical composition containing a therapeutically effective amount of an anti-C5 antibody or antigen-binding fragment thereof (such as eculizumab (SOLIRIS®) or ravelizumab (ULTOMIRIS®)) suitable for use in the methods described herein and a pharmaceutically acceptable carrier.

In one embodiment, the kit comprises: (a) a dose of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 heavy chain sequences shown as SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences shown as SEQ ID NOs: 4, 5 and 6, respectively, and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the methods described herein.

In another aspect, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ulfovirizumab (ULTOMIRIS®)) for use in preparing a human patient with CKD for CPB cardiac surgery is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following dose (e.g., unit dose): a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof for inhibiting terminal complement activation in a human patient with CKD prior to CPB cardiac surgery is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following dose (e.g., unit dose): a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof for treating a human patient with CKD prior to CPB cardiac surgery is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following dose (e.g., unit dose): a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof for preventing or reducing CSA-AKI in a human patient with CKD is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following dose (e.g., unit dose): a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof for preventing or reducing one or more MAKEs in a human patient with CKD is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose (e.g., unit dose): a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

In another aspect, the present invention provides an anti-C5 antibody or an antigen-binding fragment thereof (e.g., ultomiris®) for use in preparing a human patient with CKD for CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose (e.g., unit dose): a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

In one embodiment, an anti-C5 antibody or an antigen-binding fragment thereof is provided for inhibiting terminal complement activation in a human patient with CKD before CPB heart surgery, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before surgery in the following dose (e.g., unit dose): a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

In another embodiment, an anti-C5 antibody or antigen-binding fragment is provided for use in treating a human patient with CKD prior to CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery in the following dose (e.g., unit dose): a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, a use of an anti-C5 antibody or antigen-binding fragment for preventing or reducing CSA-AKI in a human patient with CKD is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose (e.g., unit dose): a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

In another embodiment, the use of an anti-C5 antibody or antigen-binding fragment in preventing or reducing one or more MAKEs in a human patient with chronic renal disease, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose (e.g., unit dose): a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

I. Definition

As used herein, the term "subject" or "patient" is a human patient (e.g., a patient suffering from a kidney disease, such as a chronic kidney disease).

As used herein, the term "pediatric" patient is a human patient classified by a physician or caregiver as belonging to a non-adult category, and can include, for example, newborns (both premature and full-term), infants, children, and adolescents. Typically, a pediatric patient is a patient under 18 years of age (<18 years old).

As used herein, the term "adult" patient is a patient who has been classified as a human patient by a physician or caregiver, e.g., a patient who is not a newborn, infant, child, or adolescent, e.g., based on age, developmental status, physiological characteristics, etc. Typically, an adult patient is a patient 18 years of age or older (≥ 18 years of age).

As used herein, the phrase "chronic kidney disease" (CKD) (also known as chronic renal disease) is a condition characterized by a gradual loss of kidney function over time. Diabetes and high blood pressure or hypertension are responsible for two-thirds of cases of chronic kidney disease. Other conditions or illnesses that can cause kidney disease include, but are not limited to, glomerulonephritis, genetic diseases such as polycystic kidney disease (PKD), abnormalities of the kidneys and urinary tract before birth, autoimmune diseases, or other causes such as blockage caused by kidney stones or tumors, enlarged prostate in men, or recurring urinary tract infections. Symptoms of CKD include, but are not limited to, feeling tired and lacking energy, difficulty concentrating, loss of appetite, trouble sleeping, nighttime muscle cramps, swollen ankles, puffiness around the eyes, dry and itchy skin, and/or the need to urinate more frequently, especially at night.

CKD is usually diagnosed with one or more of the following tests. One test is a urine test for the albumin to creatine ratio. Albumin is a protein that should not be found in the urine and indicates a problem with kidney function. Another test is a blood creatinine test. This test determines if there is too much creatinine (a waste product) in the blood. A third option is to test the patient's glomerular filtration rate (GFR). The GFR is calculated using the test results and other factors, such as age and sex. The results of the GFR are the best way to measure a patient's level of kidney function and determine the stage of kidney disease.

As used herein, the phrase "major adverse renal event" (MAKE) means: (1) persistent renal dysfunction (SKD), defined as a decrease in estimated glomerular filtration rate (eGFR) > 25% from baseline after CPB (e.g., where the decrease in eGFR is determined by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula based on serum cystin C (sCysC) or serum creatinine (sCr)), (2) the development of renal replacement therapy (KRT) after CPB, and/or (3) death from any cause after CPB.

As used herein, the phrase "heart-related acute kidney injury" (CSA-AKI) is an event characterized by an acute deterioration in renal function following cardiac surgery, characterized by a decline in GFR. CSA-AKI is the second most common cause of AKI in the critical care setting and is associated with increased mortality. The pathophysiology of CSA-AKI is highly complex and may include renal ischemia-reperfusion injury, inflammation, oxidative stress, hemolysis, and/or nephrotoxins.

CSA-AKI is characterized by an increase in serum creatinine (sCr) or serum cystin C (sCysC) of ≥ 0.3 mg/dL in a 48-hour period within 7 days after CPB and/or an increase in sCr or sCysC of ≥ 1.5 times baseline within 7 days after CPB. Severe CSA-AKI refers to stage 2 or 3 according to modified Kidney Disease Improving Global Outcomes (KDIGO) criteria. Human patients are not considered to have severe CSA-AKI based on the highest sCr observed after CPB (e.g., within 7, 30, 45, 60, or 90 days after CPB), as assessed by modified Risk, Injury, Failure, Renal Function Loss, and End-Stage Kidney Disease (RIFLE) criteria. Complete recovery of CSA-AKI was characterized by an sCr < 1.1 times baseline after CPB (e.g., within 7, 30, 45, 60, or 90 days after CPB). Partial recovery of CSA-AKI was characterized by an sCr ≥ 1.1 - < 1.5 times baseline (e.g., within 7, 30, 45, 60, or 90 days after CPB). Improvement of CSA-AKI was characterized by an sCr ≥ 1.5 - < 2.0 times baseline (e.g., within 7, 30, 45, 60, or 90 days after CPB). Stable CSA-AKI was characterized by an sCr ≥ 2.0 - < 3.0 times baseline (e.g., within 7, 30, 45, 60, or 90 days after CPB).

As used herein, the phrase "cardiac surgery" (also referred to as cardiovascular surgery or heart surgery) refers to any surgical procedure involving the heart or the blood vessels that carry blood to and from the heart. Examples of cardiac surgery include, but are not limited to, coronary artery bypass grafting (CABG), valve replacement or repair, insertion of a pacemaker or implantable cardioverter defibrillator (ICD), maze surgery, labyrinth surgery, heart transplantation, and insertion of a ventricular assist device (VAD) or total artificial heart (TAH), and transcatheter structural heart surgery.

CABG (also called heart bypass or coronary artery bypass surgery) is one of the most common types of heart surgery and involves taking a healthy artery or vein from somewhere else in the body and connecting it to supply blood around a blocked coronary artery. The transplanted artery or vein is passed around the blocked part of the coronary artery, creating a new path for blood to flow to the heart muscle. Often, this is done for more than one coronary artery during the same surgery.

In the case of heart valve repair or replacement, surgeons repair or replace the valve with an artificial valve or with a biological valve made from pig, cow, or human heart tissue. One repair option is to insert a catheter through a large blood vessel, guide it to the heart, and inflate and deflate a small balloon at the tip of the catheter to widen the narrow valve.

Medicines are usually the first treatment choice for arrhythmias, a condition in which the heart beats too fast, too slow, or with an irregular rhythm. If medicines don't work, a surgeon can implant a pacemaker, or ICD, under the skin in the chest or abdomen, with wires connecting it to the heart chambers. The device uses electrical pulses to control the heart's rhythm when sensors detect an abnormal heart rhythm. An ICD works similarly, but when it detects a dangerous arrhythmia, it delivers an electrical shock to restore normal rhythm.

In the case of a maze procedure, surgeons create a pattern of scar tissue in the upper chambers of the heart to redirect electrical signals along a controlled pathway to the lower heart chambers. The procedure blocks the stray electrical signals that cause atrial fibrillation, the most common type of severe heart arrhythmia.

During aneurysm repair, the weakened portion of the artery or heart wall is replaced with a patch or graft to repair the balloon-like bulge in the artery or heart muscle wall.

During a heart transplant, the diseased heart is removed and replaced with a healthy heart from a deceased donor.

A VAD is a mechanical pump that supports heart function and blood flow. A TAH replaces the two lower chambers of the heart.

In addition to these surgeries, a minimally invasive alternative to open-heart surgery that is becoming increasingly popular is transcatheter structural heart surgery. This involves guiding a long, thin, flexible tube called a catheter to the heart through a blood vessel that enters from the groin, thigh, abdomen, chest, neck, or clavicle. A small incision is required. This type of surgery includes transcatheter aortic valve implantation to replace a defective aortic valve with a valve made from animal tissue, MitraClip® implantation for mitral valve abnormalities, and WATCHMAN® implantation for patients with non-valvular atrial fibrillation.

As used herein, "cardiopulmonary bypass" (CPB) refers to a heart-lung machine used during heart surgery. A CPB provides a patient with heart and lung support while bypassing the heart and lungs. A CPB artificially provides three physiological processes or functions for a patient: (1) it adds oxygen to the blood, (2) it pumps or circulates the blood through both the cardiopulmonary bypass circuit and the patient, and (3) it removes excess carbon dioxide from the blood. To accomplish this, a surgeon inserts cannulas into the patient's main veins (usually the superior vena cava and inferior vena cava) and arteries (usually the aorta). Once the cannulas from the patient have been connected to the cardiopulmonary bypass circuit, blood is drained from the veins into the heart-lung machine while the blood is pumped into an artificial lung (oxygenator), which adds oxygen and removes carbon dioxide. The oxygenated blood is pumped back into the aorta to provide oxygen to the patient's tissues and organs. CPB may include a sternotomy and/or cross-clamping of the aorta.

As used herein, "effective treatment" refers to treatment that produces a beneficial effect, e.g., an improvement in at least one symptom of a disease or disorder. A beneficial effect can take the form of an improvement relative to a baseline, e.g., an improvement relative to a measurement or observation made before starting treatment according to the method.

The term "effective amount" refers to an amount of a pharmaceutical agent that provides a desired result (e.g., a biological, therapeutic and/or preventive result). The result can be prevention, reduction, amelioration, alleviation, reduction, delay and/or alleviation of one or more events or signs, symptoms or causes of a disease, or any other desired change in a biological system. An effective amount can be administered once or multiple times.

As used herein, the term "serum trough level" refers to the lowest level of an agent (e.g. , an anti-C5 antibody or antigen-binding fragment thereof) or drug present in the serum. In contrast, "serum peak level" refers to the highest level of an agent in the serum. "Average serum level" refers to the average level of an agent in the serum over time.

The term "antibody" describes a polypeptide comprising at least one antigen binding site of antibody origin (e.g., VH/VL region or Fv, or CDR). Antibodies include known forms of antibodies, for example, antibodies can be human antibodies, humanized antibodies, bispecific antibodies or chimeric antibodies. Antibodies can also be Fab, Fab'2, ScFv, SMIP, ^Affibody® , nanobodies or single domain antibodies. Antibodies can also be any of the following isotypes: IgG1, IgG2, IgG3, IgG4, IgM, IgA1, IgA2, IgAsec, IgD, IgE or a combination thereof. Antibodies can be naturally occurring antibodies or antibodies that have been altered by protein engineering techniques (e.g. , by mutation, deletion, substitution, conjugation with non-antibody parts). Antibodies can include, for example, one or more variant amino acids (compared to naturally occurring antibodies) that alter a property (e.g. , a functional property) of the antibody. Many such alterations are known in the art that affect, for example, half-life, effector function, and/or the patient's immune response to the antibody. The term antibody also includes artificial or engineered polypeptide constructs that contain at least one antibody-derived antigen binding site. II. Anti-C5 Antibodies

The anti-C5 antibodies described herein bind to complement component C5 ( e.g., human C5) and inhibit the cleavage of C5 into fragments C5a and C5b. As described above, such antibodies also have, for example, improved pharmacokinetic properties relative to other anti-C5 antibodies used for therapeutic purposes (e.g., eculizumab).

Anti-C5 antibodies (or VH/VL domains derived therefrom) suitable for use in the methods described herein can be produced using methods known in the art. Alternatively, art-recognized anti-C5 antibodies can be used. Antibodies that compete for binding to C5 with any of these art-recognized antibodies or antibodies described herein can also be used.

An exemplary anti-C5 antibody is Ravelizumab or an antigen-binding fragment and variant thereof comprising a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 14 and 11, respectively. Ravelizumab (also known as ULTOMIRIS®, BNJ441, and ALXN1210) is described in WO 2015134894 and U.S. Patent No. 9,079,949, the entire teachings of which are hereby incorporated by reference. Throughout this document, the terms Ravelizumab, BNJ441, and ALXN1210 are used interchangeably but all refer to the same antibody. Ravelizumab selectively binds to the human complement protein C5, inhibiting its cleavage into C5a and C5b during complement activation. This inhibition prevents the release of the proinflammatory mediator C5a and the formation of the lytic pore-forming membrane attack complex (MAC) C5b-9, while preserving the proximal or early components of complement activation (e.g., C3 and C3b) that are critical for the opsonization of microorganisms and clearance of immune complexes.

The peptide sequence of Ravelizumab registered in the KEGG drug database (https://www.kegg.jp/entry/D11054) shows that the N-terminal amino acid of the variable heavy chain is "X", but the database does not specify what X is. The Chemical Abstracts (CAS) of Ravelizumab (CAS 1803171-55-2) also shows that the N-terminal X is pyroglutamate (specified as "Chain 1 Pyroglutamate-1" in the CAS report). Although the information may appear different from the VH sequence of ravlizumab, for example, a heavy chain variable region polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 12 and/or a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 14, there is an alignment between the patent sequence and the drug database/CAS sequence because it is recognized in the art that the N-terminal Q in the polypeptide and/or antibody sequence is cyclized during process development, with the conversion rate of the drug product to pyroglutamine (Pryo-Q) approaching 100%, as disclosed in the following references: Liu et al. (J Pharm Sci. 2019 Oct;108(10):3194-3200) https://pubmed.ncbi.nlm.nih.gov/31145921/ and Nguyen et al. ( Int. J. Mol. Sci. 2017 Jul 20;18(7):1575) https://www.researchgate.net/figure/Cyclization-reactions-of-N-terminal-glutamine-and-glutamate-residues-in-a-polypeptide_fig4_318926365. Additional information is provided on page 7 and Table 4 of Xu et al. ( MAbs 2019 Feb/Mar;11(2):239–264) and in the following references: (1) Yu et al ., “Investigation of N-terminal glutamate cyclization of recombinant monoclonal antibody in formulation development,” J. Pharm. Biomed. Anal . 2006, 42, 455–463 and Dick et al., “Determination of the origin of the N-terminal pyro-glutamate variation in monoclonal antibodies using model peptides,” Biotechnol . Bioeng . [Biotechnology and Bioengineering], 2007, 97, 544–553, the disclosure of which is incorporated by reference in its entirety.

In other embodiments, the antibody comprises the heavy chain and light chain CDRs or variable regions of Ravelizumab. Thus, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the Ravelizumab VH region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the Ravelizumab VL region having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 19, 18 and 3, respectively, and the light chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 4, 5 and 6, respectively. In another embodiment, the antibody comprises the VH and VL regions having the amino acid sequences shown in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.

Another exemplary anti-C5 antibody is antibody BNJ421 or an antigen-binding fragment and variant thereof comprising a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 20 and 11, respectively. BNJ421 (also known as ALXN1211) is described in WO 2015134894 and U.S. Patent No. 9,079,949, the entire teachings of which are hereby incorporated by reference.

In other embodiments, the antibody comprises the heavy chain and light chain CDRs or variable regions of BNJ421. Therefore, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the BNJ421 VH region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the BNJ421 VL region having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 19, 18 and 3, respectively, and the light chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 4, 5 and 6, respectively. In another embodiment, the antibody comprises the VH and VL regions having the amino acid sequences shown in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.

The exact boundaries of CDRs are defined differently according to different methods. In some embodiments, the positions of CDRs or framework regions within a light or heavy chain variable domain are defined as follows: Kabat et al. [(1991) "Sequences of Proteins of Immunological Interest." NIH Publication No. 91-3242, US Department of Health and Human Services, Bethesda, Maryland]. In this case, the CDR may be referred to as a "Kabat CDR" (e.g., "Kabat LCDR2" or "Kabat HCDR1"). In some embodiments, the positions of CDRs of a light or heavy chain variable region are defined as follows: Chothia et al. ( Nature , 342:877-83, 1989). Thus, such regions may be referred to as "Chothia CDRs" (e.g., "Chothia LCDR2" or "Chothia HCDR3"). In some embodiments, the positions of the CDRs of the light and heavy chain variable regions may be defined as in the Kabat-Chothia combined definition. In such embodiments, such regions may be referred to as "combined Kabat-Chothia CDRs". Thomas, C. et al. ( Mol. Immunol. , 33:1389-401, 1996) exemplified the identification of CDR boundaries according to the Kabat and Chothia numbering schemes.

Another exemplary anti-C5 antibody is the 7086 antibody described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy chain and light chain CDRs or variable regions of the 7086 antibody (see U.S. Patent Nos. 8,241,628 and 8,883,158). In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 21, 22 and 23, respectively, and light chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 24, 25 and 26, respectively. In another embodiment, the antibody or antigen-binding fragment thereof comprises the 7086 antibody VH region having the sequence shown in SEQ ID NO:27, and the 7086 antibody VL region having the sequence shown in SEQ ID NO:28.

Another exemplary anti-C5 antibody is the 8110 antibody also described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy chain and light chain CDRs or variable regions of the 8110 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 29, 30 and 31, respectively, and light chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 32, 33 and 34, respectively. In another embodiment, the antibody comprises a 8110 antibody VH region having a sequence shown in SEQ ID NO: 35 and a 8110 antibody VL region having a sequence shown in SEQ ID NO: 36.

Another exemplary anti-C5 antibody is the 305LO5 antibody described in U.S. Patent No. 9,765,135. In one embodiment, the antibody comprises the heavy chain and light chain CDRs or variable regions of the 305LO5 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 37, 38 and 39, respectively, and light chain CDR1, CDR2 and CDR3 domains having sequences shown in SEQ ID NOs: 40, 41 and 42, respectively. In another embodiment, the antibody comprises a 305LO5 antibody VH region having a sequence shown in SEQ ID NO: 43 and a 305LO5 antibody VL region having a sequence shown in SEQ ID NO: 44.

Another exemplary anti-C5 antibody is the SKY59 antibody (Fukuzawa, T. et al., Sci. Rep. , 7:1080, 2017). In one embodiment, the antibody comprises the heavy chain and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody or its antigen-binding fragment comprises a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.

In some embodiments, the anti-C5 antibody comprises the heavy chain and light chain variable regions or the heavy chain and light chain of the REGN3918 antibody (see U.S. Patent No. 10,633,434). In some embodiments, the anti-C5 antibody or its antigen-binding fragment comprises a heavy chain variable region and a light chain variable region, the heavy chain variable region comprises the sequence shown in SEQ ID NO: 47, and the light chain variable region comprises the sequence shown in SEQ ID NO: 48. In some embodiments, the anti-C5 antibody or its antigen-binding fragment comprises the heavy chain sequence shown in SEQ ID NO: 49 and the light chain sequence shown in SEQ ID NO: 50.

In another embodiment, the anti-C5 antibody is a biosimilar of eculizumab (SOLIRIS®). For example, in one embodiment, the anti-C5 antibody is, for example, ABP 959 antibody (an eculizumab biosimilar manufactured by Amgen, USA), ELIZARIA® (an eculizumab biosimilar manufactured by Generium JNC, Russia), SB12 (an eculizumab biosimilar manufactured by Samsung Bioepis, Incheon, South Korea), ISU305 (an eculizumab biosimilar from ISU Abxis, South Korea), ABLYZE® (an eculizumab biosimilar from CinnaGen, Iran), BCD 148 (a biosimilar of eculizumab from Biocad Medical in Quebec, Canada), tertulumab (made by Novartis AG), kovalizumab (made by Roche), CAN106 (made by Beihai Kangcheng Pharmaceutical Co., Ltd. in China), or pazelimumab (made by Regeneron Pharmaceuticals).

In some embodiments, the anti-C5 antibodies described herein comprise a heavy chain CDR1 comprising or consisting of the following amino acid sequence: GHIFSNYWIQ (SEQ ID NO: 19). In some embodiments, the anti-C5 antibodies described herein comprise a heavy chain CDR2 comprising or consisting of the following amino acid sequence: EILPGSGHTEYTENFKD (SEQ ID NO: 18). In some embodiments, the anti-C5 antibody described herein comprises a heavy chain variable region comprising the following amino acid sequence: QVQLVQSGAE VKKPGASVKV SCKASGHIFS NYWIQWVRQA PGQGLEWMGE ILPGSGHTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SS (SEQ ID NO: 12).

In some embodiments, the anti-C5 antibody described herein comprises a light chain variable region, wherein the light chain variable region comprises the following amino acid sequence: DIQMTQSPSS LSASVGDRVT ITCGASENIY GALNWYQQKP GKAPKLLIYG ATNLADGVPS RFSGSGSGTD FTLTISSLQP EDFATYYCQN VLNTPLTFGQ   GTKVEIK (SEQ ID NO: 8).

In some embodiments, the anti-C5 antibodies described herein may comprise a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn) with an affinity greater than that of a natural human Fc constant region from which the variant human Fc constant region is derived. The Fc constant region may comprise, for example, one or more (e.g., two, three, four, five, six, seven, or eight or more) amino acid substitutions relative to the natural human Fc constant region from which the variant human Fc constant region is derived. The substitutions may increase the binding affinity of an IgG antibody containing a variant Fc constant region to FcRn at pH 6.0 while maintaining the pH dependence of the interaction. Methods for testing whether one or more substitutions in an antibody Fc constant region increase the affinity of the Fc constant region for FcRn at pH 6.0 (while maintaining the pH dependence of the interaction) are known in the art and exemplified in the working examples. See, for example, WO 2015134894 and U.S. Patent No. 9,079,949, the disclosures of each of which are incorporated herein by reference in their entirety.

Substitutions that enhance the binding affinity of an antibody Fc constant region for FcRn are known in the art and include, for example, (1) a triple substitution of M252Y/S254T/T256E (Dall'Acqua, W. et al., J. Biol. Chem., 281:23514-24, 2006); (2) a M428L or T250Q/M428L substitution (Hinton, P. et al., J. Biol. Chem. , 279:6213-6, 2004; Hinton, P. et al., J. Immunol., 176:346-56, 2006); and (3) a N434A or T307/E380A/N434A substitution (Petkova, S. et al., Int. Immunol., 18:1759-69, 2006). Additional substitution pairs: P257I/Q311I, P257I/N434H, and D376V/N434H (Datta-Mannan, A. et al., J. Biol. Chem. , 282:1709-17, 2007), the disclosures of each of which are incorporated herein by reference in their entirety.

In some embodiments, the variant constant region has a substitution for valine at EU amino acid position 255. In some embodiments, the variant constant region has a substitution for asparagine at EU amino acid position 309. In some embodiments, the variant constant region has a substitution for isoleucine at EU amino acid position 312. In some embodiments, the variant constant region has a substitution at EU amino acid position 386.

In some embodiments, the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or 2) amino acid substitutions, insertions, or deletions relative to the native constant region from which it is derived. In some embodiments, the variant Fc constant region comprises one or more amino acid substitutions selected from the group consisting of: M252Y, S254T, T256E, N434S, M428L, V259I, T250I, and V308F. In some embodiments, the variant human Fc constant region comprises methionine at position 428 and asparagine at position 434 of a native human IgG Fc constant region, each using EU numbering. In some embodiments, the variant Fc constant region comprises a 428L/434S double substitution as described in U.S. Patent No. 8,088,376.

In some embodiments, the exact positions of the mutations may be shifted from the natural human Fc constant region positions due to antibody engineering. For example, when used in an IgG2/4 chimeric Fc, the 428L/434S double substitution may correspond to 429L and 435S in the M429L and N435S variants found in ravlizumab and described in U.S. Patent No. 9,079,949 (the disclosure of which is incorporated herein by reference in its entirety).

In some embodiments, the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, 384, 385, 386, 387, 389, 424, 428, 433, 434, or 436 (EU numbering) relative to a native human Fc constant region. In some embodiments, the substitution is selected from the group consisting of: methionine for glycine at position 237; alanine for proline at position 238; lysine for serine at position 239; isoleucine for lysine at position 248; alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan, or tyrosine at position 250. threonine; phenylalanine, tryptophan, or tyrosine for methionine at position 252; threonine for serine at position 254; glutamine for arginine at position 255; aspartic acid, glutamine, or glutamine for threonine at position 256; alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine, or valine for proline at position 257 ; histidine substituted for glutamine at position 258; alanine substituted for aspartic acid at position 265; phenylalanine substituted for aspartic acid at position 270; alanine or glutamine substituted for asparagine at position 286; histidine substituted for threonine at position 289; alanine substituted for asparagine at position 297; glycine substituted for serine at position 298; alanine substituted for valine at position 303; Alanine is substituted for valine at position 305; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, asparagine, proline, glutamine, arginine, serine, valine, tryptophan or tyrosine is substituted for threonine at position 307; alanine, phenylalanine, isoleucine, leucine, methionine, proline at position 308 , glutamine, glutamic acid, or threonine for valine; alanine, aspartic acid, glutamine, proline, or arginine for leucine or valine at position 309; alanine, histidine, or isoleucine for glutamic acid at position 311; alanine or histidine for aspartic acid at position 312; lysine or arginine for leucine at position 314; alanine or histidine for isoleucine at position 315; asparagine; alanine substituted for lysine at position 317; glycine substituted for asparagine at position 325; valine substituted for isoleucine at position 332; leucine substituted for lysine at position 334; histidine substituted for lysine at position 360; alanine substituted for aspartic acid at position 376; alanine substituted for glutamine at position 380; alanine substituted for glutamine at position 382; alanine substituted for asparagine or serine at position 385; aspartic acid or histidine substituted for glycine at position 386; proline substituted for glutamine at position 387; glutamine substituted for proline at position 389; alanine or serine substituted for asparagine at position 424; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine at position 428 434; and a substitution of alanine, phenylalanine, histidine, serine, tryptophan, or tyrosine for asparagine at position 436, all using the EU numbering.

In some embodiments, suitable anti-C5 antibodies for use in the methods described herein comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 14 and/or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11. Alternatively, in some embodiments, anti-C5 antibodies for use in the methods described herein comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 20 and/or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11.

In one embodiment, the antibody binds to C5 with an affinity dissociation constant ( _KD ) of at least 0.1 (e.g., at least 0.15, 0.175, 0.2, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0.7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, or 0.975) nM at pH 7.4 and 25°C (and, otherwise under physiological conditions). In one embodiment, the antibody binds to C5 with an affinity dissociation constant ( _KD ) of about 0.5 nM at pH 7.4 and 25°C (and, otherwise, under physiological conditions). In some embodiments, the anti-C5 antibody or antigen-binding fragment thereof has a _KD of no greater than 1 (e.g., no greater than 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, or 0.2) nM. In some embodiments, the antibody binds to C5 with a _KD of about 22 nM at pH 6.0 and 25°C (and, otherwise, under physiological conditions).

In other embodiments, [( _KD of the antibody for C5 at pH 6.0 and 25°C)/( _KD of the antibody for C5 at pH 7.4 and 25°C)] is greater than 21 (e.g., greater than 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500, or 8000)

Methods for determining whether an antibody binds to a protein antigen and/or the affinity of an antibody for a protein antigen are known in the art. For example, the binding of an antibody to a protein antigen can be detected and/or quantified using a variety of techniques, such as, but not limited to, Western blot, dot blot, surface plasmon resonance (SPR) assay (e.g., BIAcore system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, New Jersey), or enzyme-linked immunosorbent assay (ELISA; Benny KC Lo (2004) "Antibody Engineering: Methods and Protocols," Humana Press (ISBN: 1588290921); Johne, B. et al., J. Immunol. Meth., 160:191-8, 1993; Jönsson, U. et al., Ann. Biol. Clin., 161:191-8, 1994; Jönsson, U. et al., Ann. Biol. Clin., 162:191-13, 1995; Jönsson, U. et al., Ann. Biol. Clin., 163:191-13, 1995; Jönsson, U. et al., Ann. Biol. Clin., 164:191-13, 1995; Jönsson, U. et al., Ann. Biol. Clin . , 165:191-13, 1995; Jönsson, U. et al., Ann. Biol . Clin . , 166:191-13, 1995; Jönsson, U. et al., Ann. Biol. Clin., 167 ... 51:19-26, 1993; and Jönsson, U. et al., Biotechniques , 11:620-7, 1991). In addition, methods for measuring affinities (e.g., dissociation and association constants) are described in the working examples.

As used herein, the term " _ka " refers to the rate constant for the association of an antibody with an antigen. The term " _k " refers to the rate constant for the dissociation of an antibody from an antibody/antigen complex. And the term " _K " refers to the equilibrium dissociation constant of an antibody-antigen interaction. The equilibrium dissociation constant is derived from the ratio of the kinetic rate constants, _K = _ka / _k . Such determinations can be measured, for example, at 25°C or 37°C. The kinetics of binding of an antibody to human C5 can be determined, for example, at pH 8.0, 7.4, 7.0, 6.5, and 6.0 by SPR on a BIAcore 3000 instrument using an anti-Fc capture method to immobilize the antibody.

In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof blocks the cleavage of C5 into C5a and C5b. By this blocking effect, for example, the pro-inflammatory effect of C5a and the generation of C5b-9 membrane attack complex (MAC) on the cell surface are inhibited.

Methods for determining whether a particular antibody described herein inhibits C5 cleavage are known in the art. Inhibition of human complement component C5 can reduce the cell lytic ability of complement in the subject's body fluids. Such a reduction in the cell lytic ability of a complement present in one or more body fluids can be measured by methods known in the art, for example, by a conventional hemolytic assay, such as the hemolytic assay (Kabat and Mayer (eds.), "Experimental Immunochemistry, 2nd ed.," 135-240, Springfield, IL, CC Thomas (1961), pp. 135-139), or other conventional forms of the assay, such as the chicken erythrocyte hemolysis assay (Hillmen, P. et al., N. Engl. J. Med. , 350:552-9, 2004). Methods for determining whether a candidate compound inhibits the cleavage of human C5 into C5a and C5b forms are known in the art (Evans, M. et al., Mol. Immunol. , 32: 1183-95, 1995). The concentration and/or physiological activity of C5a and C5b in body fluids can be measured, for example, by methods known in the art. For C5b, one or more hemolytic assays for soluble C5b-9 as discussed herein can be used. Other assays known in the art can also be used. Using these or other suitable types of assays, candidate agents that can inhibit human body component C5 can be screened.

Immunological techniques such as, but not limited to, ELISA can be used to measure the protein concentration of C5 and/or its cleavage products to determine the ability of anti-C5 antibodies or antigen-binding fragments thereof to inhibit the conversion of C5 into biologically active products. In some embodiments, the production of C5a is measured. In some embodiments, C5b-9 neoepitope-specific antibodies are used to detect MAC formation.

Hemolysis assays can be used to determine the inhibitory activity of anti-C5 antibodies or antigen-binding fragments thereof on complement activation. In order to determine the effect of anti-C5 antibodies or antigen-binding fragments thereof on hemolysis mediated by the classical complement pathway in an in vitro serum test solution, for example, sheep erythrocytes coated with hemolysin or chicken erythrocytes sensitized with anti-chicken erythrocyte antibodies are used as target cells. The percentage of lysis is normalized by considering 100% lysis to be equal to the lysis that occurs in the absence of an inhibitor. In some embodiments, the classical complement pathway is activated by a human IgM antibody, such as that used in the ^Wieslab® Classical Pathway Complement Kit ( ^Wieslab® COMPL CP310, Euro-Diagnostica, Sweden). Briefly, the test serum is incubated with an anti-C5 antibody or an antigen-binding fragment thereof in the presence of human IgM antibodies. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme-conjugated anti-C5b-9 antibody and a fluorescent substrate and measuring the absorbance at an appropriate wavelength. As a control, the test serum is incubated in the absence of an anti-C5 antibody or an antigen-binding fragment thereof. In some embodiments, the test serum is a C5-deficient serum reconstituted with a C5 polypeptide.

To determine the effect of anti-C5 antibodies or antigen-binding fragments thereof on alternative pathway-mediated hemolysis, unsensitized rabbit or guinea pig erythrocytes can be used as target cells. In some embodiments, the serum test solution is a C5-deficient serum reconstituted with a C5 polypeptide. The percentage of lysis is normalized by considering 100% lysis to be equivalent to the lysis that occurs in the absence of an inhibitor. In some embodiments, the alternative complement pathway is activated by lipopolysaccharide molecules, such as used in the ^Wieslab® Alternative Pathway Complement Kit ( ^Wieslab® COMPL AP330, Euro-Diagnostica, Sweden). Briefly, the test serum is incubated with an anti-C5 antibody or antigen-binding fragment thereof in the presence of lipopolysaccharide. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme-conjugated anti-C5b-9 antibody and a fluorescent substrate and measuring the fluorescence at the appropriate wavelength. As a control, the test serum is incubated in the absence of anti-C5 antibody or its antigen-binding fragment.

In some embodiments, C5 activity or its inhibition is quantified using the CH50eq assay. The CH50eq assay is a method for measuring total classical complement activity in serum. The test is a lysis assay that uses antibody-sensitized erythrocytes as activators of the classical complement pathway and various dilutions of the test serum to determine the amount (CH50) required to provide 50% lysis. For example, the percentage of hemolysis can be determined using a spectrophotometer. The CH50eq assay provides an indirect measurement of the formation of the terminal complement complex (TCC) because the TCC itself is directly responsible for the measured hemolysis. The assay is known and commonly practiced by those familiar with the art. In brief, in order to activate the classical complement pathway, an undiluted serum sample (e.g., a reconstituted human serum sample) is added to a microassay well containing antibody-sensitized erythrocytes, thereby generating a TCC. Next, the activated serum is diluted in microassay wells coated with a capture reagent (e.g., an antibody that binds to one or more components of TCC). TCC present in the activated sample binds to the monoclonal antibodies coating the surface of the microassay wells. The wells are washed and a detection reagent that detectably labels and recognizes bound TCC is added to each well. The detectable label can be, for example, a fluorescent label or an enzyme label. The assay results are expressed as CH50 unit equivalents per milliliter (CH50 U Eq/mL).

For example, inhibition related to terminal complement activity includes a decrease of at least 5% (e.g., at least 6%, 7%, 8%, 9%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55% or 60%) in, for example, a hemolytic assay or a CH50eq assay of terminal complement activity compared to the effect of a control antibody (or antigen-binding fragment thereof) under similar conditions and at equal molar concentrations. As used herein, significant inhibition means that a given activity (e.g., terminal complement activity) is inhibited by at least 40% (e.g., at least 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95% or more). In some embodiments, the anti-C5 antibodies described herein contain one or more amino acid substitutions relative to the CDRs of eculizumab (i.e. , SEQ ID NOs: 1-6), but still retain at least 30% (e.g. , at least 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95%) of the complement inhibitory activity of eculizumab in a hemolytic assay or a CH50eq assay.

The anti-C5 antibodies described herein have a serum half-life in humans of at least 20 (e.g. , at least 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, or 55) days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans of at least 40 days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans of about 43 days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans of between 39 and 48 days. Methods for measuring the serum half-life of antibodies are known in the art. In some embodiments, the serum half-life of an anti-C5 antibody or antigen-binding fragment thereof described herein is at least 20% greater (e.g., at least 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, 250%, 300%, 400%, or 500%) than the serum half-life of eculizumab, e.g., as measured in one of the mouse model systems described in the working examples (e.g., a C5-deficient/NOD/scid mouse or a hFcRn transgenic mouse model system).

In one embodiment, the antibody competes for binding to the same epitope on C5 and/or binds to the same epitope on C5 as an antibody described herein. The term "binds to the same epitope" with respect to two or more antibodies means that the antibodies bind to the same segment of amino acid residues as determined by a given method. Techniques for determining whether an antibody binds to the same epitope on C5 as an antibody described herein include, for example, epitope mapping, such as x-ray analysis of crystals of antigen:antibody complexes, and hydrogen/deuterium exchange mass spectrometry (HDX-MS). Antibodies with identical VH and VL or identical CDR1, CDR2, and CDR3 sequences are expected to bind to the same epitope.

An antibody that "competes with another antibody for binding to a target" is one that inhibits (partially or completely) the binding of another antibody to a target. Whether two antibodies compete with each other for binding to a target, i.e., whether and to what extent one antibody inhibits the binding of the other antibody to a target, can be determined using known competition assays. In certain embodiments, an antibody competes with another antibody and inhibits the binding of the other antibody to a target by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100%. The level of inhibition or competition may vary, depending on which antibody is the "blocking antibody" (i.e., the antibody that is incubated with the target first). Competing antibodies can bind, for example, to the same epitope, to overlapping epitopes, or to adjacent epitopes (e.g., as indicated by steric hindrance).

The anti-C5 antibodies or antigen-binding fragments thereof described herein for use in the methods described herein can be produced using a variety of techniques recognized in the art. Monoclonal antibodies can be obtained by various techniques familiar to those skilled in the art. Briefly, spleen cells from animals immunized with the desired antigen are usually immortalized by fusion with myeloma cells (Köhler, G. and Milstein, C., Eur. J. Immunol. [European Journal of Immunology], 6:511-9, 1976). Immortalization methods include transformation with Epstein Barr Virus, oncogenes or retroviruses or other methods known in the art. Colonies from single immortalized cells are screened for the production of antibodies with the desired specificity and affinity for the antigen, and the yield of monoclonal antibodies produced by such cells can be increased by various techniques, including injection into the peritoneal cavity of a vertebrate host. Alternatively, DNA sequences encoding monoclonal antibodies or binding fragments thereof can be isolated by screening DNA libraries from human B cells (Huse, W. et al., Science , 246:1275-81, 1989). III. Composition

Also provided herein are compositions comprising anti-C5 antibodies or antigen-binding fragments thereof. In one embodiment, the composition comprises an anti-C5 antibody or antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 domains in a heavy chain variable region having a sequence as shown in SEQ ID NO: 12, and CDR1, CDR2 and CDR3 domains in a light chain variable region having a sequence as shown in SEQ ID NO: 8. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having sequences as shown in SEQ ID NO: 14 and 11, respectively. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having sequences as shown in SEQ ID NO: 20 and 11, respectively.

The composition can be formulated as a pharmaceutical solution, for example, for administration to a subject according to any of the methods described herein. The pharmaceutical composition typically comprises a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" refers to and includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic agents and absorption delaying agents, etc. that are physiologically compatible. The composition may comprise a pharmaceutically acceptable salt, such as an acid addition salt or a base addition salt, a sugar, a carbohydrate, a polyol and/or a tonicity modifier.

The compositions may be formulated according to standard methods. Pharmaceutical formulation is an established field (see, e.g., Gennaro (2000) "Remington: The Science and Practice of Pharmacy", 20th ed., Lippincott, Williams & Wilkins (ISBN: 0683306472); Ansel et al. (1999) "Pharmaceutical Dosage Forms and Drug Delivery Systems", 7th ed., Lippincott Williams & Wilkins Publishers (ISBN: 0683305727); and Kibbe (2000) "Handbook of Pharmaceutical Excipients American Pharmaceutical Association [American Medical Association Handbook of Drug Formulations]" 3rd Edition (ISBN: 091733096X)). In some embodiments, the composition can be formulated, for example, as a buffer solution of suitable concentration and suitable for storage at 2°C-8°C (e.g., 4°C). In some embodiments, the composition can be formulated for storage at a temperature below 0°C (e.g., -20°C or -80°C). In some embodiments, the composition can be formulated for storage at 2°C-8°C (e.g., 4°C) for up to 2 years (e.g., 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, 1½ years, or 2 years). Thus, in some embodiments, the compositions described herein are stable when stored at 2°C-8°C (e.g., 4°C) for at least 1 year.

Pharmaceutical compositions can be in various forms. Such forms include, for example, liquid, semisolid and solid dosage forms, such as liquid solutions (e.g., injectable and infusible solutions), dispersions or suspensions, tablets, pills, powders, liposomes and suppositories. The preferred form depends in part on the intended mode of administration and therapeutic application. For example, a composition containing a composition intended for systemic or local delivery can be in the form of an injectable or infusible solution. Thus, the composition can be formulated for administration by parenteral means (e.g., intravenous, subcutaneous, intraperitoneal or intramuscular injection). As used herein, "parenteral administration" or "administered parenterally" and other grammatically equivalent phrases refer to modes of administration other than enteral and topical administration, usually by injection, and include, but are not limited to, intravenous, intranasal, intraocular, pulmonary, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intrapulmonary, intraperitoneal, transtracheal, subcutaneous, subcutaneous, intraarticular, subcapsular, subarachnoid, intraspinal, epidural, intracerebral, intracranial, intracarotid, and intrasternal injection and infusion. IV. METHODS

Provided herein are methods of preparing human patients for surgery (e.g., cardiopulmonary bypass (CPB) heart surgery) in specific subpopulations (e.g., human patients with kidney disease, including chronic kidney disease (CKD)), methods of inhibiting terminal complement activation in human patients, methods of treating human patients with CKD prior to CPB heart surgery, methods of preventing or reducing (e.g., minimizing) cardiac surgery-associated acute kidney injury (CSA-AKI) in human patients with CKD, and methods of preventing or reducing (e.g., minimizing) one or more MAKEs in human patients with CKD.

In one embodiment, the dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the patient's weight. For example, in one embodiment, a dose of 2700 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 30 to < 40 kg. In another embodiment, a dose of 3000 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg. In another embodiment, a dose of 3300 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg. In another embodiment, a dose of 3600 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg. In certain embodiments, the dosage regimen is adjusted to provide the best desired response (e.g. , an effective response).

In one aspect, a method is provided for preparing a human patient (e.g., a human patient with kidney disease, including CKD) for surgery (e.g., CPB heart surgery), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In another embodiment, a method for preparing a human patient (e.g., a human patient with kidney disease, including CKD) for surgery (e.g., CPB heart surgery) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery.

In another embodiment, a method for preparing a human patient with CKD for CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: e)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; f)   For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; g)  For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or h)  For patients with a body weight of ≥ For a 100 kg patient, 3600 mg.

In another aspect, a method for inhibiting terminal complement activation in a human patient (e.g., a human patient with kidney disease, including CKD) prior to surgery (e.g., CPB heart surgery) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In one embodiment, a method is provided for inhibiting terminal complement activation in a human patient (e.g., a human patient with kidney disease, including CKD) before surgery (e.g., CPB heart surgery), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery.

In another embodiment, a method for inhibiting terminal complement activation in a human patient with CKD before CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d) For patients weighing ≥ 100 kg, 3600 mg.

In some embodiments, according to the methods described herein, terminal complement activation is inhibited in a human patient as assessed by any suitable assay. In one embodiment, the method inhibits terminal complement activation in a human patient by, e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%.

In another aspect, a method for treating a human patient with kidney disease (e.g., CKD) prior to cardiac surgery (e.g., using CPB) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In one embodiment, a method is provided for treating a human patient with a kidney disease (e.g., CKD) prior to cardiac surgery (e.g., using CPB), wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery.

In another embodiment, a method for treating a human patient with CKD before CPB cardiac surgery is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery in the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d) For patients weighing ≥ 100 kg, 3600 mg.

In another aspect, a method for preventing or reducing CSA-AKI in a human patient with kidney disease (e.g., CKD) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, and wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to cardiac surgery (e.g., using CPB).

In one embodiment, a method for preventing or reducing CSA-AKI in a human patient with a kidney disease (e.g., CKD) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises the CDR1, CDR2, and CDR3 heavy chain sequences shown in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences shown in SEQ ID NOs: 4, 5, and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB).

In another embodiment, a method for preventing or reducing CSA-AKI in a human patient with CKD is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB) at the following doses: a)   For patients weighing ≥ 30 to < 40 kg, 2700 mg; b)   For patients weighing ≥ 40 to < 60 kg, 3000 mg; c)   For patients weighing ≥ 60 to < 100 kg, 3300 mg; or d)  For patients weighing ≥ 100 kg, 3600 mg.

In another aspect, a method for preventing or reducing one or more MAKEs in a human patient suffering from a kidney disease (e.g., CKD) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to cardiac surgery (e.g., using CPB).

In one embodiment, a method for preventing or reducing one or more MAKEs in a human patient suffering from a kidney disease (e.g., CKD) is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB).

In another embodiment, a method for preventing or reducing one or more MAKEs in a human patient with CKD is provided, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before cardiac surgery (e.g., using CPB) in the following doses: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)   For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or d)  For patients weighing ≥ 100 kg, 3600 mg.

In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient at least one calendar day prior to surgery (e.g., CPB heart surgery). In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered one to seven calendar days prior to surgery. For example, in one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered one, two, three, four, five, six, or seven calendar days prior to surgery. V. Conclusion

In certain embodiments, the methods described herein provide an optimal desired response (e.g., inhibition of terminal complement activation) in a human patient (e.g., a human patient with a kidney disease, including CKD) prior to surgery (e.g., heart surgery with CPB), prevention or reduction of CSA-AKI in a human patient with a kidney disease (e.g., CKD) undergoing surgery (e.g., heart surgery with CPB), and/or prevention or reduction of one or more MAKEs in a human patient with a kidney disease (e.g., CKD) undergoing surgery (e.g., heart surgery with CPB).

In certain embodiments, the methods described herein are sufficient to maintain a specific serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof. In one embodiment, for example, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 186, 187, 188, 189, 190, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215 80, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 35 5, 360, 365, 37 0, 375, 380, 385, 390, 395, 400, 405, 410, 415, 420, 425, 430, 435, 440, 445, 450, 455, 460, 465, 470, 475, 480, 485, 490, 495, 500, 505, 510, 515, 520 ,525,530,53 5, 540, 545, 550, 555, 560, 565, 570, 575, 580, 585, 590, 595, 600, 605, 610, 615, 620, 625, 630, 635, 640, 645, 650, 655, 660, 665, 670, 675, 680, 685, 690, 695, 700 µg/mL or higher. In one embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at 100 µg/mL or more, 150 µg/mL or more, 200 µg/mL or more, 250 µg/mL or more, 300 µg/mL or more, 350 µg/mL or more, 400 µg/mL or more, or 450 µg/mL or more. In another embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at between 100 µg/mL and 700 µg/mL, preferably between 300 µg/mL and 600 µg/mL. In another embodiment, the method maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at about 475 µg/mL. In another embodiment, the method maintains a peak serum concentration of the anti-C5 antibody or antigen-binding fragment thereof at less than about 1800, 1780, 1760, 1740, 1720, 1700, 1680, 1660, 1640, 1620, 1600, 1580, 1560, 1540, 1520, 1500, 1480, 1460, 1440 In some embodiments, the method maintains the peak serum concentration of the anti-C5 antibody or antigen-binding fragment thereof between 900 μg/mL and 1800 μg/mL, preferably between 1050 μg/mL and 1550 μg/mL. In another embodiment, the method maintains a peak serum concentration of anti-C5 antibody or antigen-binding fragment thereof at about 1350 μg/mL.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and at a frequency to maintain at least 50 µg, 55 µg, 60 µg, 65 µg, 70 µg, 75 µg, 80 µg, 85 µg, 90 µg, 95 µg, 100 µg, 105 µg, 110 µg, 115 µg, 120 µg, 125 µg, 130 µg, 135 µg, 140 µg, 145 µg, 150 µg, 155 µg, 160 µg, 165 µg, 170 µg, 175 µg, 180 µg, 185 µg, 190 µg, 195 µg, 200 µg, 205 µg, 210 µg, 215 µg, 220 µg, 225 µg, 230 µg, 235 µg, 240 µg, 245 µg, 250 µg, 255 µg, 260 µg, 270 µg, 280 µg, 290 µg, 300 µg, 320 µg, 340 µg, 360 µg, 380 µg, 400 µg, 420 µg, 440 µg, 460 µg, 480 µg, 500 µg, 550 µg, 600 µg, 650 µg, 700 µg, 750 µg, 800 µg, 850 µg, 900 µg, 950 µg, 1000 µg, 1050 µg, 1100 µg, 1150 µg, 1200 µg, 1250 µg, 1300 µg, 1350 µg, 1400 µg, 1450 µg, 1500 µg, 1550 µg, 1600 µg, 1650 µg, 1700 µg, 1750 µg or more, for example 1800 µg antibody/mL patient blood.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and frequency that maintains a minimal free C5 concentration. In one embodiment, for example, the anti-C5 antibody or antigen-binding fragment thereof is administered to the patient in an amount and frequency that maintains a free C5 concentration of 0.5 μg/mL or less (e.g., 0.4 μg/mL, 0.3 μg/mL, 0.2 μg/mL, or 0.1 μg/mL or less).

The efficacy of the methods provided herein can be assessed using any suitable means. In one embodiment, a single preoperative weight-based dose of an anti-C5 antibody or antigen-binding fragment thereof results in complete C5 inhibition for at least 18 days.

In one embodiment, the method inhibits terminal complement activation in a human patient as assessed by any suitable assay. In one embodiment, the method inhibits terminal complement activation in a human patient by, e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%.

In another embodiment, the methods described herein prevent the need for renal replacement therapy (KRT).

In another embodiment, the method prevents or reduces CSA-AKI in a human patient with CKD. In one embodiment, CSA-AKI is characterized by: a)   Increase in serum creatinine (sCr) or serum cystin C (sCysC) by ≥ 0.3 mg/dL in a 48-hour period within 7 days after CPB and/or b)  Increase in sCr or sCysC by ≥ 1.5 times baseline within 7 days after CPB or at 15, 30, 60, or 90 days after CPB.

In another embodiment, the human patient does not have severe CSA-AKI (stage 2 or 3) based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB as assessed by modified Kidney Disease Improving Global Outcomes (KDIGO) criteria, as shown in Table 1 of the Examples (see also KDIGO., Kidney Inter. Suppl . 2013;3:1-150 and Khwaja A., Nephron. Clin. Pract. 2012 ; 120(4):c179-184).

In another embodiment, the human patient does not have severe CSA-AKI based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB as assessed by the modified Risk, Injury, Failure, Renal Function Loss, and End-Stage Kidney Disease (RIFLE) criteria, as shown in Table 2 of the Examples (see also Bellomo R et al., Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8(4):R204-R212).

In another embodiment, the method results in an improvement in renal function staging after CSA-AKI, as shown in Table 3 of the Examples (see also Chawla LS et al. , Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol . 2017;13(4):241-257).

In another embodiment, the method results in stable CSA-AKI characterized by sCr ≥2.0 - <3.0 times baseline within 7, 30, 45, 60, or 90 days after surgery.

In another embodiment, the method results in improvement in CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the improvement is characterized by sCr ≥1.5 - <2.0 times baseline.

In another embodiment, the method results in partial recovery of CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the partial recovery is characterized by sCr ≥ 1.1 - < 1.5 times baseline.

In another embodiment, the method results in complete recovery of CSA-AKI within 7, 30, 45, 60, or 90 days after surgery, wherein the complete recovery is characterized by sCr < 1.1 times baseline.

In another embodiment, the method prevents or reduces one or more MAKEs in a human patient with CKD. In one embodiment, the one or more MAKEs are persistent renal dysfunction (SKD), defined, for example, as an estimated glomerular filtration rate (eGFR) after CPB that is > 25% lower than baseline, wherein the reduction in eGFR is determined by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula based on serum cystin C (sCysC) or serum creatinine (sCr). In another embodiment, the one or more MAKEs are the occurrence of renal replacement therapy (KRT) after CPB. In another embodiment, the one or more MAKEs are death from any cause after CPB.

In another embodiment, the method results in a change from baseline in quality of life as assessed via a quality of life assessment. For example, in one embodiment, the quality of life assessment is the Kidney Disease Quality of Life Instrument (KDQOL-36™). The KDQOL-36™ is a 36-item kidney-specific health-related quality of life measure that includes the Short Form Health Survey 12-item (SF-12) as a general core plus the Kidney Disease Burden, Kidney Disease Symptoms/Problems, and Kidney Disease Impact scales.

In another embodiment, the quality of life assessment is the European Quality of Life Group 5 Dimensions 5 Levels (EQ-5D-5L). The EQ-5D-5L is a self-assessed standardized tool for measuring health-related quality of life and has been widely used for a wide range of health conditions. The EQ 5D 5L includes 5 dimensions, each describing a different aspect of health: mobility, self-care, daily activities, pain/discomfort, and anxiety/depression.

In another implementation, the quality of life measure is the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale. The FACIT scale is a 13-item questionnaire that assesses self-reported fatigue and its impact on daily activities and functioning over the previous 7 days.

In another embodiment, the method results in a change to normal levels of a biomarker associated with vascular inflammation (e.g., abscess tumor necrosis factor receptor 1 [TNF-R1]). In another embodiment, the method results in a change to normal levels of a biomarker associated with endothelial injury and/or activation (e.g., thrombomodulin). In another embodiment, the method results in a change to normal levels of a biomarker associated with renal injury (e.g., neutrophil gelatin-associated lipocalin [NGAL]). In another embodiment, the method results in a change to normal levels of a biomarker associated with a cell cycle arrest inducer (e.g., tissue inhibitor of metalloproteinase-2 [TIMP-2]). In another embodiment, the method results in a shift toward normal levels of complement proteins and complement activation pathway products (e.g., soluble C5b-9). VI. Kits and Unit Dosage Forms

Also provided herein is a kit comprising a pharmaceutical composition containing a therapeutically effective amount of an anti-C5 antibody or an antigen-binding fragment thereof (such as Ravelizumab) suitable for use in the aforementioned methods, and a pharmaceutically acceptable carrier. The kit may also include instructions as needed, including, for example, a dosing schedule, to allow a practitioner (e.g., a physician, nurse, or patient) to administer the composition contained therein to administer the composition to a patient. The kit may also include a syringe.

Optionally, the kit includes multiple packages of single-dose pharmaceutical compositions, each package containing an effective amount of anti-C5 antibody or antigen-binding fragment thereof for single administration according to the methods provided above. Instruments or equipment required for administering one or more pharmaceutical compositions may also be included in the kit. For example, the kit may provide one or more pre-filled syringes containing a certain amount of anti-C5 antibody or antigen-binding fragment thereof.

In one embodiment, the kit includes: (a) a dose of an anti-C5 antibody or antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in any of the methods described herein. VI. Uses

In another aspect, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ralizumab (ULTOMIRIS®)) is provided for use in preparing a human patient with CKD for CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof for inhibiting terminal complement activation in a human patient with CKD prior to CPB cardiac surgery is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof is provided for treating a human patient with CKD prior to CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof for preventing or reducing CSA-AKI in a human patient with CKD is provided, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, an anti-C5 antibody or an antigen-binding fragment thereof is provided for preventing or reducing one or more MAKEs in a human patient with CKD, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another aspect, the present invention provides an anti-C5 antibody or an antigen-binding fragment thereof (e.g., ulfovirizumab (ULTOMIRIS®)) for use in preparing a human patient with CKD for CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In one embodiment, an anti-C5 antibody or an antigen-binding fragment thereof is provided for inhibiting terminal complement activation in a human patient with CKD before CPB heart surgery, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before surgery at the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3600 mg for patients with a body weight of ≥ 100 kg.

In another embodiment, an anti-C5 antibody or antigen-binding fragment is provided for use in treating a human patient with CKD before CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, the use of an anti-C5 antibody or antigen-binding fragment for preventing or reducing CSA-AKI in a human patient with CKD, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

In another embodiment, the use of an anti-C5 antibody or antigen-binding fragment in preventing or reducing one or more MAKEs in a human patient with chronic renal disease, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg.

The following examples are illustrative only and should not be construed in any way as limiting the scope of the present disclosure, as many variations and equivalents will be apparent to those skilled in the art after reading the present disclosure. The contents of all references, Genbank entries, patents, and published patent applications cited throughout this application are expressly incorporated herein by reference. Example Example: Phase 3 Study of Ravelizumab ( ULTOMIRIS® ) to Protect Patients with Chronic Kidney Disease ( CKD ) from Cardiac Surgery-Associated Kidney Injury ( CSA-AKI ) and / or Subsequent Major Adverse Renal Events ( MAKE )

CKD patients undergoing CPB heart surgery are at increased risk for CSA-AKI. Although CSA-AKI occurs in 20%-25% of patients in the broad population undergoing CPB heart surgery, in the case of CKD it occurs in 60%-80% of patients, with MAKE occurring in 20%-30% of patients. Inhibition of terminal complement damage to the kidney and vasculature could reduce the incidence, severity, and duration of postoperative CSA-AKI and subsequent MAKE, thereby improving long-term survival and avoiding renal replacement therapy (KRT), and reducing the progression of CKD.

Therefore, a randomized, placebo-controlled, double-blind study design was performed to minimize bias and balance the effects of confounding factors in this complex and highly comorbid population. Participants in both treatment groups received standard care as background therapy throughout the study. 1.   Study Design

This was a phase 3, randomized, double-blind, placebo-controlled, multicenter study of ravulizumab in adult participants with CKD and stable heart disease undergoing CPB with non-emergency sternotomy for coronary artery bypass grafting (CABG), valve replacement or repair, or combined surgery to reduce the risk of postoperative AKI and MAKE 90 days after surgery (MAKE90). A schematic diagram of the trial design is shown in Figure 1. Participants considered at risk for AKI after CPB had an eGFR ≥ 20 to < 60 mL/min/1.73m2 with a minimum Society of Thoracic Surgeons (STS) calculator risk of renal failure score of 3%.

The study included a 28-day screening period, randomization and medication administration within 1-7 days before CPB, a primary evaluation period of 90 days after CPB, and a 365-day survival follow-up period after CPB.

Approximately 736 participants were randomized in a 1:1 ratio to receive either ravulizumab or placebo. Randomization was stratified by baseline CKD stage (3A, 3B, 4) and type of surgery (mitral valve replacement or combined surgery vs other single surgery).

Eligible participants were randomized to receive a single weight-based dose of ravulizumab or placebo. Randomization and dosing occurred on the same day, unless preparation for the study intervention was required the day before dosing. Dosing must have occurred at least 1 day before surgery, and surgery must have occurred between 1 and 7 days after dosing. The dosing date was Day 1 for each participant. During the primary assessment period, all treated participants were followed for 90 days after CPB surgery and survival follow-up was completed at Day 365 after CPB. The total study duration was approximately 400 days. A participant was considered to have completed the study if he/she had completed the primary assessment period.

The analysis of the primary evaluation period was performed when all participants had completed that period. In addition, two interim analyses were performed in this study, one after approximately 30% and one after 50% of the randomized participants had completed the primary evaluation period, to assess early inefficacy in the first interim analysis and to assess the need for sample size adjustment in the second interim analysis.

Study end was defined as the date the last participant completed the last visit, as indicated in the activity timeline (see Figures 2A- 2G ) .

This is a 2-arm, parallel-group treatment study that is blinded to subjects and investigators. Ravelizumab is being evaluated in adults with CKD undergoing CPB for CABG, valve replacement or repair, or a combination of procedures to determine if it can reduce the risk of death, the need for KRT, and the persistence of decline in renal function.

Randomized sick participants received a single weight-based dose of ravulizumab or placebo within 1 to 7 days before CPB surgery (i.e., at the latest 1 day before surgery). 2.    Objectives, measures, and endpoints

The primary objective of this study was to evaluate the efficacy of Ravelizumab in reducing the risk of MAKE90 after CPB. The main measures were: (1) Treatment: Ravelizumab or placebo; (2) Population: Adult participants with CKD; (3) Endpoints/variables: MAKE at day 90 after CPB (MAKE90), defined as meeting at least one of the following criteria: a decrease of ≥ 25% from baseline in eGFR (CKD-EPI formula using sCysC) at day 90 after CPB, or initiation of KRT at day 90 after CPB, or death from any cause within 90 days after CPB; (4) Intercurrent events (IEs): IE1: iodinated contrast dye exposure after treatment administration up to day 90 after CPB; IE2: surgery without CPB or surgery without CPB within 15 days after administration; and IE3: use of confounding interventions before surgery or use of non-permitted interventions after treatment administration up to day 90 after CPB. Treatment strategy: Analyze collected endpoints independent of IE; and (5) Summary measure: Differences between treatment groups in the proportion of participants experiencing MAKE at 90 days after CPB, regardless of any IE.

The key secondary efficacy objectives of this study were to evaluate the efficacy of revlizumab in reducing the risk of AKI after CPB (based on sCr) based on the following: (1) freedom from CSA-AKI at day 90 after CPB, (2) freedom from severe CSA-AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 7 days after CPB; (3) freedom from any severe AKI (RIFLE injury or failure criteria) based on the highest sCr observed within 30 days after CPB; (4) freedom from any severe AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 30 days after CPB; (5) freedom from any RIFLE failure criteria based on the highest sCr observed within 30 days after CPB; and (6) all-cause mortality from randomization to day 90 after CPB.

Another secondary efficacy objective was to evaluate the efficacy of ravulizumab in reducing the risk of MAKE (based on sCysC), MAKE (based on sCr), AKI (based on sCr), and related outcomes after CPB. Corresponding endpoints and/or estimators included: (1) MAKE and its components (excluding sCysC-based MAKE90) at 30, 60, and 90 days after CPB, the occurrence of KRT or death at 30, 60, and 90 days after CPB, (2) the highest CSA-AKI stage within 3 and 7 days after CPB, (3) freedom from CSA-AKI at 15, 30, and 60 days after CPB, (4) freedom from any AKI at 3, 7, 15, 30, 60, and 90 days after CPB, and (5) for those who experienced CSA-AKI within 7 days after CPB, AKI progression at 15, 30, 60, and 90 days after CPB: complete recovery, partial recovery, improvement, stability, or worsening.

Healthcare resource utilization objectives were to evaluate the effect of ravulizumab on healthcare resource utilization in subjects with CKD undergoing non-emergency CPB, as assessed by: (1) length of index hospitalization and ICU stay, (2) ventilator-free days at days 30 and 90 after CPB, (3) readmission rate (all-cause or AKI-related) at days 30 and 90 after CPB, and (4) KRT days at days 30 and 90 after CPB.

Health-related QoL objectives are, for example, assessing the effect of ravulizumab on quality of life in subjects with CKD undergoing non-urgent CPB by: (1) change from baseline in KDQOL-36™ at 30, 60, and 90 days after CPB, (2) change from baseline in EQ-5D-5L at 30, 60, and 90 days after CPB, and (3) change from baseline in FACIT-Fatigue at 30, 60, and 90 days after CPB.

Another objective was to assess the PK and PD of ravlizumab in participants with CKD undergoing non-urgent CPB, as measured by ravlizumab serum concentrations and absolute values, changes from baseline, and percentage changes from baseline in serum free C5 concentrations.

Another objective was to evaluate the safety of ravulizumab IV in participants with CKD undergoing non-urgent CPB, as measured by the incidence of TEAEs and TESAEs and changes from baseline in laboratory parameters at scheduled visits.

Another objective was to evaluate the immunogenicity of ravulizumab IV in participants with CKD undergoing non-urgent CPB, such as ADA incidence, ADA response class, and titer at day 90 after CPB.

Exploratory objectives are assessment of baseline biomarkers and changes in response to treatment, for example, via assessment of biomarkers that may include, but are not limited to, activation of the pro-inflammatory pathway (e.g., plasma and urine soluble C5b-9), renal injury (e.g., urine neutrophil globulin-associated lipocalin [NGAL]), and endothelial injury (e.g., plasma thrombomodulin [TM]).

The ultimate objective was to evaluate the efficacy of sCysC-based ravulizumab in reducing the risk of CSA-AKI, as measured by sCysC-based AKI within 7 days of CPB: highest AKI stage according to KDIGO criteria and absence of severe AKI (KDIGO stage 2 or 3).

The endpoint definitions listed in Table 1 were used in this study. [ Table 1 ] : Endpoint Definition End Definition MAKEXX (based on sCysC), MAKEXX (based on sCr) (XX = 30, 60, or 90) Meet at least 1 of the following criteria: • ≥ 25% decrease from baseline in eGFR on Day XX as determined by the CKD-EPI formula using sCysC (for sCysC-based MAKEXX) or the CKD-EPI formula using sCr (for sCr-based MAKEXX), or • KRT initiation by Day XX, or • Death from any cause by Day XX AKI (based on sCr), AKI (based on sCysC) Meet any of the following modified KDIGO criteria: • Increase in sCr (for sCr-based AKI) or sCysC (for sCysC-based AKI) ≥ 0.3 mg/dL during any 48-hour interval • Increase in sCr or sCysC ≥ 1.5 times baseline within 3 and 7 days after CPB or at 15, 30, 60, or 90 days AKI staging (KDIGO criteria; based on sCr) Meet modified KDIGO criteria for stage 1, 2, or 3 as outlined in Table 2, No CSA-AKI on day XX after CPB (based on sCr) (XX = 15, 30, 60, or 90) Meet any of the following criteria: • No experience of CSA-AKI within 7 days after CPB • Achieved recovery from AKI on day XX after experiencing CSA-AKI within 7 days after CPB Severe CSA-AKI (KDIGO criteria; based on sCr) Stage 2 or 3 AKI within 7 days after CPB based on the highest observed sCr Severe AKI (KDIGO criteria; based on sCr) Fulfilling modified KDIGO criteria for stage 2 or 3 AKI as outlined in Table 2 based on the highest sCr observed within 30 days after CPB Severe AKI and failure (RIFLE criteria; based on sCr) Based on the highest sCr observed within 30 days after CPB, meeting the modified RIFLE criteria for injury or failure as outlined in Table 3 and isolated failure No AKI on day XX after CPB (based on sCr) (XX = 3, 7, 15, 30, 60, or 90) sCr < 1.5 times baseline value on day XX after CPB AKI recovery (based on sCr) Complete: • sCr < 1.1 times baseline Partial: • sCr ≥ 1.1 - < 1.5 times baseline AKI improvement (based on sCr) • Move down 1 or more stages from the highest CSA-AKI (except stage 0) as outlined in Table 4 or • Remain at stage 3 but discontinue KRT Stable AKI (based on sCr) • No change in AKI or KRT status Worsening of AKI (based on sCr) • Move up 1 or more stages from the highest CSA-AKI stage, or • Remain at stage 3 but start KRT Abbreviations: AKI = acute renal injury; CKD-EPI = chronic kidney disease epidemiology group; CPB = cardiopulmonary bypass; CSA-AKI = acute renal injury associated with cardiac surgery; eGFR = estimated glomerular filtration rate; KDIGO = kidney disease-improvement global outcome; KRT = renal replacement therapy; MAKE = major adverse renal events; RIFLE = risk, injury, failure, renal loss, and end-stage renal disease; sCr = serum creatinine; sCysC = serum cysteine C

The primary estimand of this study was to estimate the treatment effect using a treatment strategy based on the intention-to-treat analysis set, regardless of any intercurrent events (IEs) and participant compliance with IP dosing. This estimand was designed to provide a population-level estimate of the treatment effect on the binary endpoint of MAKE90 after CPB in CKD patients who met the study eligibility criteria and were randomized into the study. The main measures included the following 4 attributes: A.   Population: Adult participants with CKD as defined by inclusion and exclusion criteria B.   Variable: MAKE at day 90 after CPB (MAKE90) C.   Intercurrent events (IE): IE1: Exposure to iodinated contrast dye after administration of treatment until day 90 after CPB IE2: Surgery without CPB or surgery without CPB within 15 days after administration IE3: Use of confounding interventions before surgery or administration of treatment until day 90 after CPB with a non-permitted intervention. Note: Treatment strategy: The collected endpoints were analyzed independently of the IE. D.   Summary measure: Difference between treatment groups in the proportion of participants experiencing MAKE at 90 days after CPB, regardless of any IE.

Key secondary estimators were designed to provide population-level estimates of treatment effects on five binary endpoints, regardless of any IE. The estimators for each key secondary endpoint will target the same estimators as the primary endpoint as follows: A.   Population: Adult participants with CKD as defined by inclusion and exclusion criteria B.   Variables: Freedom from CSA-AKI at day 90 after CPB; Freedom from severe CSA-AKI (Kidney Disease Improvement Global Outcomes [KDIGO] stage 2 or 3) based on the highest sCr observed within 7 days after CPB Freedom from any severe AKI (Risk, Injury, Failure, Renal Loss, and End-Stage Kidney Disease [RIFLE] injury or failure criteria) based on the highest sCr observed within 30 days after CPB; Freedom from any severe AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 30 days after CPB; Based on the highest sCr observed within 30 days after CPB without any RIFLE failure criteria; All-cause mortality from randomization to day 90 after CPB C.   Intercurrent events (IE): IE1: Exposure to iodinated contrast dye after administration of treatment until day 90 after CPB; IE2: Surgery without CPB or surgery without CPB within 15 days after administration; IE3: Use of confounding intervention before surgery or use of non-permitted intervention after administration of treatment until day 90 after CP Treatment strategy: The collected endpoints were analyzed independently of IE. Summary measures: Differences between treatment groups in the proportion of participants experiencing key secondary endpoint events. 3.    MAKE and CSA-AKI

The primary outcome measure (MAKE) was conceived to capture clinical outcomes after AKI and was defined as mortality, need for KRT , and SKD, defined as a >25% decrease in estimated glomerular filtration rate (eGFR) from baseline by the CKD -EPI formula (see, e.g., Billings FT et al., Nephron. Clin. Pract. 2014 ; 127(1-4):89-93; Haverich A et al. , Ann. Thorac. Surg. 2006 ;82(2):486-492; Levey AS et al., Ann. Intern. Med . 2009;150(9):604-612; and Palevsky PM et al., Clin. J. Am. Soc. Nephrol . 2012;7(5):844-850). SKD develops as a result of unresolved AKI and represents continued worsening of CKD at 90 days. SKD is associated with a multiple-fold higher risk of long-term mortality and progression to ESKD when compared with those without AKI or who have recovered from AKI (see, e.g., Ishani A et al., J. Am. Soc. Nephrol. 2009;20(1):223-228; Wu VC et al., Kidney Int. 2011;80(11):1222-1230; and Cho JS et al. , J. Thorac. Cardiovasc. Surg. 2021;161(2):681-8).

Skeletal muscle atrophy is widely recognized as a complication after cardiac surgery (van Venrooij LM et al., Nutrition (Burbank, Los Angeles County, Calif). 2012;28(1):40-45) and can confound sCr-based estimates of eGFR. sCysC was used to calculate SKD in the MAKE endpoint, as recommended in the KDIGO guidelines (KDIGO, 2013) for this setting. Data from observational and randomized controlled intervention trials reporting AKI and MAKE outcomes after cardiopulmonary bypass were used to inform the MAKE 90 placebo rate assumption of 25%.

According to the modified KDIGO criteria, the occurrence of postoperative CSA-AKI was defined as one of the following observations within 7 days after surgery with CPB: (1) an increase in sCr of ≥ 0.3 mg/dL over a 48-hour period or (2) an increase in sCr of ≥ 1.5 times baseline within 7 days after CPB.

As defined in Table 2, the highest AKI stage by modified KDIGO criteria was determined for those occurring within 3 and 7 days after surgery with CPB (see also KDIGO., Kidney Inter. Suppl . 2013;3:1-150 and Khwaja A., Nephron. Clin. Pract. 2012 ; 120(4):c179-184). In addition, this stage was used to assess AKI occurring at any time within 30 days after CPB based on the highest observed sCr; and AKI at 15, 30, 60, and 90 days after CPB. Although the KDIGO criteria are widely adopted, in some settings (eg, the STS renal failure risk calculator), there is greater familiarity with the RIFLE criteria (eg, O'Brien SM et al., Ann Thorac Surg. 2018 ; 105(5):1419-1428). Therefore, AKI staging based on the modified RIFLE criteria was assessed for AKI at any time within 30 days after CPB based on the highest observed sCr, and the staging criteria are summarized in Table 3 (see also, Bellomo R et al., Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8(4):R204-R212). The reliable interpretation of sCysC changes in the setting of AKI is exploratory in this study as it has not yet been defined and is not commonly used for the definition or staging of AKI at this time. [ Table 2 ]: Acute Kidney Injury ( AKI ) Staging by Modified KDIGO Criteria AKI stages Definition 1 Serum creatinine (sCr) increases ≥ 0.3 mg/dL (up to < 2.0 times baseline) during a 48-hour period, or sCr increases to ≥ 1.5 - < 2.0 times baseline 2 sCr increased to ≥ 2.0 - < 3.0 times baseline 3 An increase in sCr to ≥ 3.0 times baseline, or an increase in sCr to ≥ 4.0 mg/dL in patients meeting AKI criteria, or initiation of renal replacement therapy (KRT). Note: The use of surgical ultrafiltration as a standard of care procedure for routine management of fluid balance during cardiac surgery is not considered initiation of KRT. [ Table 3 ] : AKI staging by modified RIFLE criteria AKI stages Definition Risk sCr increased to ≥ 1.5 - < 2.0 times baseline Damage sCr increased to ≥ 2.0 - < 3.0 times baseline Exhaustion sCr increases to ≥ 3.0 times baseline, or sCr increases to ≥ 4.0 mg/dL, an increase of at least 0.5 mg/dL from baseline, or KRT is initiated. Note: Use of surgical ultrafiltration as a standard of care procedure for routine management of fluid balance during cardiac surgery is not considered initiation of KRT.

Post-CPB progression (based on sCr or need for KRT) was assessed on days 15 to 90 after CPB as a function of the change in AKI from the highest CSA-AKI stage observed within the first 7 days after CPB to characterize AKI progression (recovery, improvement, stability, or worsening). Stages of post-CPB progression are defined in Table 4 (see also Chawla LS et al., Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol . 2017;13(4):241-257). [ Table 4 ]: CSA-AKI post-renal function stages to determine the progression of AKI after surgery (e.g., day 15 to day 90 ) Post- AKI Staging Definition 0 Complete recovery: sCr < 1.1 times baseline value Partial recovery: sCr ≥ 1.1 - < 1.5 times baseline value 1 sCr ≥1.5 - ＜ 2.0 times baseline value 2 sCr ≥2.0 - ＜ 3.0 times baseline value 3 sCr ≥ 3.0 times baseline, or sCr ≥ 4.0 mg/dL in patients meeting CSA-AKI criteria, or KRT

There was uncertainty regarding the underlying assumptions about the specific background MAKE rates in this risk group and the treatment efficacy assumptions. Therefore, two interim analyses of this study were performed to determine futility and the need for sample size re-estimates.

According to the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and Good Clinical Practice (GCP) guidelines, the safety outcomes being evaluated are usually used in clinical studies. 4.    Rationale for dosing

The dosing in this study was the same weight-based maintenance dose of ravlizumab that is approved for use in adults with aHUS, PNH, or gMG and for which safety has been established.

This dose ensures a revlizumab serum concentration of ≥ 175 µg/mL to achieve complete terminal complement inhibition while maintaining a maximum revlizumab serum concentration below the highest observed value of 3000 µg/mL from all completed clinical studies for at least 18 days in the target patient population. The 175 µg/mL threshold was previously determined to be the therapeutic minimum concentration of revlizumab required to achieve complete terminal complement inhibition.

To support this dosing regimen, model-based simulations were performed (Revilizumab CSA-AKI Dosing Principle, 2022). In brief, the population PK model used for simulations was derived from the aHUS label extension file. Factors that could potentially affect the PK of Revilizumab in the target patient population were incorporated into the model simulations, including the effects of proteinuria, red blood cell transfusions, and postoperative hemodilution.

Other unquantifiable factors, such as CPB-induced drug loss or activation of infusion pathways, were not included in the simulations. Therefore, dosing that would achieve ravelizumab concentrations above 175 µg/mL for at least 18 days in the setting of CSA-AKI is expected and predicted using the recommended single weight-based ravelizumab dose.

A participant was considered to have completed the study if he/she had completed the primary assessment period. Study end was defined as the date the last participant completed the last visit, as indicated in the activity schedule. 5.    Study Population

To be eligible for this study, participants must meet all of the following criteria: 1.   Age ≥ 18 to ≤ 90 years at the time of signing the informed consent. 2.   Male or female. Female participants of childbearing potential and male participants must follow protocol-specified contraception guidelines. 3.   Weight ≥ 30 kg at screening. 4.   Planned non-emergency sternotomy with CPB for the following procedures: multi-vessel CABG, valve replacement or repair; ascending aorta surgery is allowed if combined with aortic valve replacement/repair, CABG and valve combination surgery; single-vessel CABG is allowed when combined with valve replacement/repair. NOTE: Surgery should be scheduled within 35 days of screening (maximum 28-day screening period, randomization and dosing within 1-7 days before CPB). 5.   Known CKD (stage 3A, 3B, or 4) with eGFR ≥ 20 to < 60 mL/min/1.73m2 for at least 3 months, confirmed eGFR at screening (can be repeated once during screening) and randomized by sCr or sCysC measurement using the CKD-EPI equation, obtained by local or central laboratory. 6.   Presence of postoperative AKI risk as defined by a minimum STS calculator renal failure risk score of 3%. 7.   Ability to sign informed consent, including compliance with the requirements and restrictions outlined in the informed consent form and this protocol.

Participants were excluded from the study if they met any of the following criteria: 1. Anticipated acute or rescue cardiac surgery at screening or randomization, as assessed by the investigator. 2. Planned single-vessel CABG without valvular surgery. 3. Planned non-cardiopulmonary bypass surgery (e.g., surgery without CPB). 4. Any use of KRT within 30 days of randomization or presence of AKI (AKI defined as a 1.5× increase in sCr over baseline), except for transient (≤ 5 days) stage 1 AKI after iodinated contrast exposure. 5. Recipient of solid organ or bone marrow transplant. 6. Cardiogenic shock, hemodynamic instability, use of an intra-aortic balloon pump, extracorporeal membrane oxygenation, or left ventricular assist device within 72 hours of randomization. 7. Active systemic bacterial, viral, or fungal infection within 14 days prior to randomization. 8. Participants with a known history of human immunodeficiency virus (HIV) with a detectable viral load within 1 year of screening who are not receiving antiretroviral therapy or, if receiving treatment, have a known history of human immunodeficiency virus (HIV) with a detectable viral load within 1 year of screening. 9. Congenital immunodeficiency. 10. History of unexplained recurrent infection. 11. Known medical or psychological conditions that the investigator believes may interfere with the participant's full participation in the study, pose any additional risk to the participant, or confound the participant's assessment or study outcomes, including medication abuse or risk factors. 12. History of Neisseria meningitidis infection ( N. meningitidis ) infection or unresolved. 13. Hypersensitivity reactions to any component contained in the study intervention, including hypersensitivity reactions to mouse proteins. 14. Current malignancy or current treatment for malignancy 15. Use of any complement inhibitor, or plasma depletion or plasma exchange within one year prior to screening, or planned use during the study. 16. Planned use of any agent specifically used to prevent or treat AKI. 17. Planned use of KRT, intra-aortic balloon pump, extracorporeal membrane oxygenation, or left ventricular assist device between randomization and surgery. 18. Participation in another interventional treatment study or use of any experimental therapy within 30 days prior to the start of the study intervention on Day 1 of this study or within 5 half-lives of the IP (whichever is greater), or planned participation/use during the study. 19. Presence of no-resuscitation order or life expectancy < 3 months. 20. Pregnancy, breastfeeding, or intent to conceive within 8 months after the study intervention dose. 21. Participant is unwilling to receive anti-Neisseria meningitidis vaccination or to receive prophylactic treatment with appropriate antibiotics (if required).

Screening failures are defined as participants who consented to participate in a clinical study but were not subsequently randomized to a study intervention. A minimum set of screening failure information is needed to ensure transparency in reporting of participants who fail screening, to meet the Consolidated Standards of Reporting Clinical Trials (CONSORT) publication requirements and to respond to inquiries from regulatory agencies. Minimum information includes demographics, details of the screening failure (e.g., failure to pass eligibility criteria), and any adverse events (AEs) occurring during the screening period, including any serious adverse events (SAEs) and any relevant concomitant medications.

Individuals who do not meet the criteria for participation in this study for reasons that are expected to resolve or have resolved (screen failures) may be rescreened based on discussion and consensus. Participants who are rescreened outside of the screening window will be asked to sign a new Informed Consent Form (ICF). 6.    Study Intervention

A study intervention is defined as any investigational intervention, commercially available product, or placebo intended to be administered to study participants according to the study protocol.

Participants were randomly assigned to receive either revlizumab or placebo. Revlizumab was formulated at pH 7.0 and provided in 30 mL single-use vials. Each vial of revlizumab contained 300 mg revlizumab (10 mg/mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80, and water for injection. The reference product (placebo) was formulated as a matching sterile solution containing the same buffer components but without the active ingredient. Additional details are given in Table 5. [ Table 5 ] : Study Intervention Study Intervention Name Ravelizumab Placebo Dosage formula Vial Vial Physical Description Liquid solutions that are virtually particle-free Liquid solutions that are virtually particle-free Unit dose strength 300 mg (10 mg/mL concentrate) Placebo Investment channels Intravenous infusion Intravenous infusion use Experimental Placebo reference

Participants randomized to the revlizumab group received a single weight-based dose of revlizumab 1-7 days (i.e., at least 1 calendar day) before the CPB procedure. This dose is the same as the weight-based maintenance dose of revlizumab approved for use in adult patients with aHUS, PNH, or gMG (Table 6). [ Table 6 ] : Single weight-based dose of revlizumab or placebo Weight Dosage ≥ 30 to < 40 kg 2700 mg ≥ 40 to < 60 kg 3000 mg ≥ 60 to < 100 kg 3300 mg ≥ 100 kg 3600 mg

Research interventions should be labeled with at least: protocol number, batch number/expiration date, name and address, and instructions for use and storage. Research interventions should be labeled according to national regulatory requirements.

Upon arrival of the study intervention at the study site, the study intervention kit was removed from the shipping container and stored in its original carton under refrigeration at 2°C to 8°C (35°F to 47°F) and protected from light. The study intervention was not frozen. The investigator must confirm that all received study interventions maintained appropriate temperature conditions during shipment and report and resolve any discrepancies prior to use of the study intervention. The study intervention was stored in a secure, restricted access storage area with temperature monitored daily.

Study intervention infusions were prepared using aseptic technique. Eculizumab and placebo were further diluted 1:1 with compatible diluents. Eculizumab and placebo were administered through a 0.2 μm filter during infusion.

Only participants enrolled in the study may receive research interventions, and only authorized site staff may provide or administer research interventions. All research interventions must be stored according to labeled storage conditions in a secure, environmentally controlled, and monitored (manual or automated) area, with access restricted to investigators and authorized site staff.

In this study, participants in both treatment groups received standard care as background therapy.

Eligible participants were randomly assigned to either the ravulizumab group or the placebo group in a 1:1 ratio. Randomization was performed centrally using an interactive response technique (IRT).

To balance the effects of potential confounders between the ravulizumab and placebo groups, randomization was stratified by baseline CKD stage (3A, 3B, 4) confirmed by CKD-EPI using sCr or sCysC (local or central laboratory results) at screening and baseline, and by type of surgery (mitral valve replacement or combination surgery vs other single surgery).

Participants, all study center personnel, and any designated personnel directly involved in the conduct of the study were blinded to participant treatment assignment throughout the study. Blinding was maintained by using identical study intervention kits and labels for ravelizumab and placebo. The placebo had the same appearance as ravelizumab. The randomization code was maintained by the IRT provider.

Infusions of study interventions to participants are supervised by the Investigator or his/her designee to ensure that participants receive the appropriate dose at the appropriate time during the study. The date and time of dose administration are recorded. Concomitant Therapy

Any medication or treatment (including over-the-counter or prescription medications, vaccines, vitamins and/or herbal supplements) deemed necessary for the care of the participant or treatment of any adverse events during the study, as well as any other medications, except those listed as not permitted, may be given at the investigator's discretion. The investigator is responsible for recording all medications along with the following: reason for use, date of administration (including start and end dates), and dosing information, including dosage and frequency.

Participants were prohibited from receiving any of the following medication endpoints (day 90 after CPB): eculizumab, ravelizumab (except for protocol-specified study interventions), or other agents acting on the parasite pathway, plasma depletion, or plasma exchange, as well as the use of any agent specifically used to prevent or treat AKI (e.g., experimental or investigational fenodapam, levosimendan, and nesiritide, etc.). These therapies may be used for their approved indications.

The use of KRT, intra-aortic balloon pumps, extracorporeal membrane oxygenation, or left ventricular assist should be avoided after administration of the study intervention and prior to surgery unless clinically indicated. The use of these procedures after administration of the study intervention and prior to surgery is considered a confounding procedure because they could trigger AKI prior to CPB or confound the appropriate diagnosis and staging of AKI (e.g., use of KRT). These procedures are considered standard of care during and postoperative periods and are permitted.

This study does not allow for dose modification of the study intervention for individual participants. 7.    Study Assessments and Procedures

Study procedures and their timing are summarized in the Assessment Timeline shown in Figure 2. No protocol waivers or exemptions will be permitted. Adherence to study design requirements, including those specified in the Assessment Timeline, is essential to the conduct of the study. All screening assessments must be completed and reviewed to confirm that potential participants meet all eligibility criteria. A screening log is maintained to record details of all screened participants and to confirm eligibility or record reasons for screening failure, as applicable.

Procedures obtained as part of the participant's routine clinical management (e.g., blood cell counts) prior to signing the informed consent may be used for screening purposes, provided that the procedure meets the protocol-specified criteria and is performed within the time frame defined in the assessment schedule.

Duplicate or unplanned samples may be obtained for safety reasons or technical problems with the samples.

Before conducting any research related procedures, the investigator or a qualified designee must obtain signed and dated informed consent from each participant. Every effort should be made to ensure participant compliance with research participation before conducting screening procedures.

All inclusion and exclusion criteria must be reviewed by the investigator or qualified designee to ensure that participants are eligible for the study. The investigator maintains a screening log to record details of all screened participants and confirm eligibility or record reasons for screening failure, as applicable. Eligibility to participate is determined prior to randomization.

This study was designed to enroll participants who were undergoing non-emergency cardiac surgery, at the discretion of the investigators. As a guide, elective cardiac surgery was described by Bojar RM., “Manual of Perioperative Care in Adult Cardiac Surgery,” 6th edition 2021 printing ISBN: 9781119582557 and was as follows: The patient's cardiac function was stable in the days or weeks before surgery and/or the surgery could be delayed without increasing the risk of compromised cardiac outcomes.

Emergency cardiac surgery was defined as surgery required during the same hospital stay to minimize the chance of further clinical deterioration. This included, but was not limited to: worsening or sudden onset of chest pain, heart failure, acute myocardial infarction, underlying anatomy, unstable angina with intravenous nitroglycerin (IV NTG), and quiescent angina. Any of these conditions would require the patient to remain in the hospital until surgery could be performed, but the patient was able to wait for surgery until the next available OR scheduled time. Surgery may need to be delayed due to attempts to improve the patient's condition, obtain spousal or parental consent, obtain blood products, or obtain the results of necessary laboratory procedures or tests. The definition of emergency surgery included the use of an IABP, however the use or planned use of an IABP was excluded solely in this study.

Participants who required urgent or rescue cardiac surgery, as determined by the investigator, were not enrolled. As a guide, urgent cardiac surgery was defined as the prompt performance of surgery for persistent, refractory (difficult, complex, and/or uncontrollable), unrelenting cardiac damage with or without hemodynamic instability that was unresponsive to any treatment modality other than cardiac surgery. Examples include hemodynamic picture of shock supported by chemical or mechanical means (e.g., IV inotropes or IABP to maintain cardiac output), pulmonary edema requiring intubation and ventilation, prolonged myocardial infarction, signs of persistent ischemia (i.e., ECG changes), acute native valve dysfunction (acute papillary muscle rupture or leaflet tear), prosthetic valve dysfunction with structural failure (valve rupture or leaflet tear, thrombosis, pannus development that blocks flow through the valve orifice, or valve dehiscence), acute aortic dissection, rupture or dissection during cardiac catheterization; and perforation, tamponade after cardiac catheterization.

Rescue cardiac surgery was defined as patients who underwent CPR on the way to the OR before induction of anesthesia or had ongoing ECMO to sustain life.

Demographic parameters, including age, sex, race, and ethnicity (necessary for calculation of STS risk score and eGFR), were recorded in the Clinical Research Report (CRF).

Due to its mechanism of action, use of ravulizumab increases the susceptibility of participants to infection with N. meningitidis. To reduce the risk of infection, all participants must have been vaccinated against N. meningitidis within 3 years prior to the administration of the study intervention. Vaccination occurred during screening or at any time until discharge if the participant had not been vaccinated within 3 years of the study intervention. If the study intervention was administered < 2 weeks after the initial vaccination, antibiotics to prevent meningococcal infection should be administered to participants up to 2 weeks after vaccination. Participants who were hospitalized could be vaccinated after the study intervention but before discharge. These participants received prophylactic treatment with appropriate antibiotics for at least 2 weeks after vaccination, starting on the day of administration.

Vaccination against serotypes A, C, Y, W135 and, where available, serotype B (if recommended by local guidelines) is recommended to protect against commonly pathogenic meningococcal serotypes. Participants must receive a complete primary vaccination series and be revaccinated as directed by current national vaccination guidelines. Vaccination may not be adequate to protect against meningococcal infection.

The use of prophylactic antimicrobial agents should follow official guidelines and local practice. Monitor all participants for early signs of meningococcal infection and promptly assess if infection is suspected and treat with appropriate antibiotics if necessary.

To increase risk awareness and facilitate rapid disclosure of any potential signs or symptoms of meningococcal infection that participants experienced during the study, participants were provided with a Participant Safety Card to carry with them at all times. Additional discussion and explanation of potential risks, signs, and symptoms occurred as part of the Participant Safety Card review at specific time points and throughout the study as outlined in the Assessment Schedule.

Participants' relevant medical history, including prior and concomitant conditions/disorders, treatment history, and disease status of relevant illnesses, will be assessed at Screening and recorded in the original file and CRF. All medical history and prior medications and surgeries for the 2 years prior to Screening will be recorded, as well as any history at any time related to cardiac or renal disease, including the participant's identified cause of renal disease. Any changes in medical history that occurred during the Screening Period and prior to the administration of study interventions on Day 1 will be recorded prior to Study Intervention Administration

The Society of Thoracic Surgeons (STS) risk calculator was used to determine the preoperative risk of severe AKI (RIFLE failure criteria) based on baseline participant characteristics required by the risk calculator. Risk scores and participant characteristics used to determine their risk scores were obtained during the screening period before administration of study intervention on Day 1. EuroScore was calculated separately, and its value was recorded.

Home visits are permitted after discharge from the hospital when available. Home visits are conducted by qualified healthcare professionals in accordance with all national, state, and local laws or regulations of applicable regulatory agencies. Telemedicine visits may occur in conjunction with home visits.

All assessments may be performed during the home visit under the supervision of the investigator. The information collected must be forwarded to the investigator's site for evaluation on the day of the visit. In the event of any symptoms or signs indicating a serious adverse event, further evaluation of the participant may be required at the site or acute care facility. 8.    Efficacy Assessments

For the primary efficacy endpoint, participants were evaluated for major acute renal events (MAKE) at 90 days after CPB cardiac surgery. MAKE90 was defined as meeting at least 1 of the following criteria: (1) a ≥ 25% decrease in eGFR (CKD-EPI formula using sCysC) from baseline at day 90 after CPB, or (2) initiation of KRT by day 90 after CPB, or (3) death from any cause by day 90 after CPB.

In addition, secondary endpoints assessed both AKI and MAKE endpoints at additional time points. To achieve these efficacy assessments, investigators collected and recorded: A.  sCr and sCysC on the day of screening, day of medication administration (Day 1), day of surgery before induction of anesthesia, days 1-7, 15, 30, 60, and 90 after CPB, and at discharge: sCr and sCysC were collected daily from Days 1 to 7 after CPB (168 h, Visit 5) unless the participant was discharged before Day 7 after CPB. However, even after discharge or recovery (<1.5x baseline), whichever came first, the presence of AKI was tracked with daily laboratory examinations until Day 7 after CPB. B.  The highest sCr observed by the local laboratory was recorded from the end of CPB to Day 30. C. Any KRT use from randomization to day 90 post-CPB. Record type/modality, frequency, start/stop, and reason for start/stop of KRT. Every effort must be made to collect and record at least KRT status (yes/no) at days 15, 30, 60, and 90. Use of surgical ultrafiltration as a standard of care procedure for routine management of fluid balance during cardiac surgery is not considered initiation of KRT and is recorded as a concomitant procedure. D. Any death from randomization to day 90 post-CPB. Collect and record date of death and report any relevant adverse events/serious adverse events, including causal serious adverse events leading to death. Every effort must be made to collect and record at least vital status (alive, yes/no) at days 15, 30, 60, and 90

Every effort was made to collect laboratory test specimens, KRT status, KRT details, and survival status at all visits. However, if necessary, KRT status (yes/no), KRT details, and survival could be determined directly by telephone or telemedicine visit. If attempts to contact participants directly failed, KRT status and survival status could be obtained indirectly from family members, other healthcare providers, or local death registries.

The planned timing of all safety assessments is provided in the Assessment Timeline.

Symptom-directed examinations may be performed as needed at any time after screening based on local practice/standards of care; normal findings or findings consistent with the participant's medical history are not recorded; abnormal findings, new abnormalities, or worsening of physical findings not attributed to the participant's medical history are reported as adverse events. Investigators must pay special attention to clinical signs associated with preexisting serious illness. Height is measured only at screening. Weight is measured before induction of anesthesia on the day of surgery. Daily weight is measured for the first 7 days after CPB or until discharge, whichever comes first. If accurate weight cannot be obtained in the intensive care unit (ICU) setting, total daily fluid inputs and outputs are recorded in lieu of weight measurement. Assess temperature (°C or °F), heart rate, respiratory rate, and systolic and diastolic blood pressure (mmHg). Assess blood pressure and pulse measurements with the participant in a sitting position using a fully automated device. In situations where the participant cannot tolerate measurements in a sitting position (e.g., while on mechanical ventilation in the ICU), measurements may be performed and recorded as supine. Use manual techniques only when automated equipment is not available. Allow the participant to rest in a quiet environment without distractions (e.g., television, cell phones) for at least 5 minutes before measuring blood pressure and pulse. Ideally, the same arm is used for measurements for each participant. Collect vital signs before dosing on Day 1.

An electrocardiogram (ECG) may be obtained as needed at any time after screening based on local practice/standards of care. Normal findings or findings consistent with the participant's medical history are not recorded. Abnormal findings not attributable to the participant's medical history, new abnormalities, or worsening of previous ECG findings are reported as adverse events. Participants must lie supine for approximately 5-10 minutes prior to the ECG and remain supine but awake during the ECG.

All protocol-required laboratory assessments were performed according to the laboratory manual and assessment schedule. Samples were collected for clinical laboratory assessments as follows: prior to administration of study intervention on Day 1, prior to induction of anesthesia on the day of surgery, at any time during other visits, and within 1 day of discharge. On days 1-7 post-CPB, daily collection of specimens for clinical laboratory evaluations was performed as follows: sCr and sCysC were collected on days 1, 2, 4, 5, and 6 post-CPB while hospitalized, with full laboratory evaluations on days 3 and 7 post-CPB, sCr and sCysC were not collected on days 1, 2, 4, 5, or 6 if discharged before day 7 post-CPB and participants did not have AKI, and daily laboratory testing was performed for participants who developed any AKI (at least stage 1 according to KDIGO criteria) within the first 7 days, regardless of discharge status or recovery (<1.5 times baseline) by day 7 post-CPB, whichever occurred first. On days 3 and 7, specimens for clinical laboratory evaluations were collected as described in the evaluation schedule.

Repeat all safety laboratory tests with values considered clinically significant during study participation until the values return to normal or baseline or are no longer considered clinically significant at the 90th day visit. If the values do not return to normal/baseline within a certain period of time, the cause should be investigated.

If a safety laboratory value from a non-protocol-specified laboratory assessment performed at the institution's local laboratory requires a change in participant management or is considered clinically significant (e.g., an adverse event or severe adverse event or dose modification), the result is recorded in the CRF and the corresponding adverse event or severe adverse event is reported.

Pregnancy testing was performed on all women of childbearing potential (WOCBP) at protocol-specified times during the assessment schedule. Pregnancy testing could also be performed at any time during the study. A negative pregnancy test was required for WOCBP prior to administration of the study intervention. Any female participant who became pregnant during study participation would discontinue the study intervention. Pregnancy was not considered an adverse event unless there was suspicion that the study intervention may have interfered with the effectiveness of contraceptive medications. However, pregnancy complications and abnormal outcomes of pregnancy were adverse events and may meet the criteria for serious adverse events (e.g., ectopic pregnancy, spontaneous abortion, intrauterine fetal death, neonatal death, or congenital anomaly).

During the primary assessment period, vital status (alive yes/no) was recorded at 15, 30, 60, and 90 days after CPB. For participants who withdrew their informed consent for further participation in the study, every effort was made to collect data at the time of withdrawal. During the survival follow-up period, vital status was recorded for 365 days after CPB or ED, whichever occurred first.

Participants' vital status was obtained by telephone contact with the participant, the participant's family, by contact with another healthcare provider, or from the local death registry. 9.    Adverse Events (AEs) and Serious Adverse Events (SAEs)

An AE is any untoward medical event that occurs to a participant in a clinical study administered a medicinal product and that does not necessarily have a causal relationship to that treatment. Thus, an AE can be any unfavorable and unexpected sign (including abnormal laboratory findings), symptom, or disease (new or worsening) transiently associated with the use of an investigational intervention, whether or not it is considered related to the investigational intervention.

The following events meet the definition of an AE: A. Any abnormal laboratory test result (hematology, clinical chemistry, or urinalysis) or other safety assessment (e.g., ECG, radiology scan, vital signs measurement), including those that are worsening from baseline and considered clinically significant (i.e., not related to progression of underlying disease). B. Worsening of a chronic or intermittent pre-existing condition, including an increase in the frequency and/or intensity of the condition. C. A new condition detected or diagnosed after administration of the study intervention, although it may have been present before the start of the study. D. Signs, symptoms, or clinical sequelae of suspected drug interactions. E. Signs, symptoms, or clinical sequelae of suspected overdose of the study intervention or concomitant medication. An overdose itself is not reported as an AE/SAE unless it is an intentional overdose with possible suicidal/suicidal intent. Such overdoses are reported regardless of sequelae.

Events that do not meet the definition of an AE include: A.  Medical or surgical procedures (e.g., endoscopy, appendectomy): the condition leading to the procedure is an AE, and the procedure itself is recorded as a concomitant procedure. Situations where no adverse medical event occurred (e.g., hospitalization for elective surgery planned before signing the ICF, admission for social reasons or convenience). B.  Expected daily fluctuations of pre-existing diseases or conditions that were present or detected at the start of the study and have not worsened. C.  Medication errors (including intentional misuse, abuse, and overdose of a drug) or uses not defined in the protocol are not considered AEs unless the adverse medical event is due to a medication error. D. Pregnancies occurring during maternal or paternal exposure to the study intervention should be reported within 24 hours of the investigator/site becoming aware of them. Data on fetal outcome and breastfeeding are collected for regulatory reporting and safety evaluations. E. Any clinically significant abnormal laboratory finding or other abnormal safety evaluation related to a potential disease, unless the investigator determines that the severity is beyond what would be expected given the participant’s condition. F.   The disease/disorder being studied or the expected progression, signs, or symptoms of the disease/disorder being studied, unless the severity is beyond what would be expected given the participant’s condition. G.   Circumstances in which adverse medical events did not occur (social and/or facilitated hospital admissions). H. “Lack of efficacy” or “failure of expected pharmacological action” per se are not reported as AEs or SAEs. Such conditions are captured in the efficacy assessment. However, signs, symptoms, and/or clinical sequelae due to lack of efficacy are reported as AEs or SAEs if they meet the definition of an AE or SAE.

If an event does not fall within the definition of an AE above, it will not qualify as an SAE even if it meets the severity criteria (e.g., hospitalization due to signs/symptoms of the disease under study, death due to disease progression).

A SAE was defined as any adverse medical event at any dose that met one or more of the criteria listed in Table 7. [ Table 7 ] : SAE 1. Cause death 2. Life-threatening • The term “life-threatening” in the definition of “serious” refers to an event in which the participants are at risk of death at the time of the event. It does not refer to an event that could have resulted in death if it were more serious. 3. Requirement for Hospitalization or Prolonged Hospitalization • In general, hospitalization means that a participant has been involuntarily retained in a hospital or emergency room (usually including a stay of at least one night) for observation and/or treatment that would not be appropriate in a physician’s office or outpatient setting. Complications that occur during hospitalization are AEs. An event is serious if the complication prolongs the hospitalization or meets any other severity criteria. An AE should be considered serious when there is doubt as to whether a hospitalization occurred or was necessary. • Hospitalization for elective treatment of a pre-existing condition that did not worsen compared to baseline is not considered an AE. 4. Resulting in persistent disability / incapacity • The term disability refers to a significant impairment in a person’s ability to carry out normal life functions. • The definition is not intended to include experiences of relatively minor medical significance, such as uncomplicated headaches, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g., a sprained ankle), which may interfere with or prevent daily life functioning but do not constitute a substantial interruption. 5. Congenital malformation / birth defect 6. Other Situations: • Medical or scientific judgment should be used in determining whether an SAE report is appropriate for other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may endanger the participant or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definitions. Such events should generally be considered serious events. • Examples of such events include invasive or malignant cancer, intensive treatment in the emergency department or at home for allergic bronchospasm, blood dyscrasias, or seizures that do not result in hospitalization, or the development of drug dependence or drug abuse.

Suspected Unexpected Serious Adverse Reactions (SUSARs) are defined as events that are assessed as serious, are not listed in the appropriate reference safety information (IB), and have been assessed to have at least a reasonable possibility that the event is related to the investigational medicinal product.

The intensity of each AE and SAE reported during the study was rated by the investigator and assigned to one of the following categories in the National Cancer Institute CTCAE v5.0, released on November 27, 2017: Grade 1: Mild (signs or symptoms are noticed but easily tolerated), Grade 2: Moderate (not severe enough to interfere with normal activities), Grade 3: Severe (incapacitating, unable to perform normal activities), Grade 4: Life-threatening, or Grade 5: Fatal. An event was defined as “severe” when it met at least one of the predefined outcomes described in the SAE definition, but not when it was rated as severe.

The investigator is obligated to assess the relationship between the study intervention and each AE or SAE that occurs. The investigator must provide a causality assessment for all AEs (both minor and major). This assessment must be documented on the eCRF and any other forms, as appropriate. Causality assessments are defined as follows: A.  Unrelated: There is no reasonable possibility that the study intervention caused the AE. The AE has a more likely alternative etiology; this may be due to the underlying disease or concurrent disease, a complication, concurrent treatment, or the effect of another concurrent medication. The event does not have a reasonable temporal relationship to the administration of the study intervention. B.  Related: There is a reasonable possibility that the study intervention caused the AE. The AE has a temporal relationship to the administration of the study intervention. The event does not have a possible alternative etiology. The event is consistent with the known pharmacopeia of the study intervention. Improvement after discontinuation and/or recurrence after re-attack

The Investigator used clinical judgment to determine the relationship. Other causes, such as underlying illness, concomitant treatments, and other risk factors, as well as the temporal relationship of the event to the administration of the study intervention were considered and investigated. The Investigator also reviewed the IB and/or product information (for marketed products) in his/her assessment. For each AE/SAE, the Investigator was required to document in the Medical Note that they had reviewed the AE/SAE and provided an assessment of causality.

Intravenous and infusion-related reactions are a potential risk of monoclonal antibody use; these reactions may be non-immune or immune-mediated (e.g., hypersensitivity reactions). Signs and symptoms may include headache, fever, facial flushing, itching, myalgia, nausea, chest tightness, dyspnea, vomiting, erythema, abdominal discomfort, sweating, tremor, hypertension, dizziness, hypotension, palpitations, and lethargy. Signs and symptoms of hypersensitivity or anaphylaxis may include urticaria, swelling of the face, eyelids, lips or tongue, or dyspnea.

All administration, IV, and infusion-related reactions were reported to the Investigator and qualified designees. The Investigator and qualified designees were responsible for detecting, documenting, and recording events that met the definition of an AE or SAE and for continuing to follow up on events that were serious, believed to be related to the study intervention or study procedures; or that led to participant discontinuation of revlizumab. Participants who experienced reactions during revlizumab administration were treated according to institutional guidelines. Participants who experienced severe reactions during revlizumab administration leading to revlizumab discontinuation underwent all planned safety, PK, and PD evaluations required by the protocol. All AEs that could indicate an infusion-related reaction were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 or higher.

If an allergic reaction occurs based on the criteria listed in Table 8, consider subcutaneous administration of epinephrine (1/1000, 0.3 mL to 0.5 mL, or equivalent). In the case of bronchospasm, also consider treatment with an inhaled beta-agonist. Participants who are given antihistamines for the treatment or prevention of infusion-related reactions should be given appropriate warnings regarding somnolence and impaired driving ability before discharge. [ Table 8 ] : Clinical criteria for diagnosis of allergic reactions An allergic reaction is likely to occur when any one of the following three criteria is met : • Acute onset (minutes to hours) of illness involving the skin, mucosal tissues, or both (e.g., generalized urticaria, itching or flushing, lip-tongue-uvula swelling) and at least 1 of the following: o Respiratory compromise (e.g., dyspnea, wheezing-bronchospasm, stridor, decreased peak expiratory flow, hypoxemia) o Hypotension or symptoms associated with end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence) • Two or more of the following that develop rapidly (minutes to hours) after the participant is exposed to the possible allergen: o Involvement of dermato-mucosal tissues (e.g., generalized urticaria, itching-flushing, swelling of lips/tongue/uvula) o Respiratory impairment (e.g., dyspnea, wheezing/bronchial spasm, stridor, decreased peak expiratory flow, hypoxemia) o Decreased blood pressure or related symptoms (e.g., hypotonia [collapse], syncope, incontinence) o Persistent gastrointestinal symptoms (e.g., spasmodic abdominal pain, vomiting) • Decrease in blood pressure (minutes to hours) after the participant is exposed to a known allergen: o Systolic blood pressure decreases by less than 90 mmHg or by more than 30% from the participant's baseline

Meningococcal infection was considered an adverse event of special interest (AESI).

For this study, any dose of the study intervention greater than that specified in the protocol was considered an overdose. If the dose could not be determined due to blinding, a suspected overdose was defined by the volume administered.

Unintentional overdoses or suspected overdoses not associated with any laboratory abnormality or clinical symptoms were not considered AEs. Investigators were required to report overdoses within 24 hours, regardless of whether they were associated with an AE.

Overdose is a medication error that is not considered an AE unless there is an adverse medical event caused by the overdose. 10. Pharmacokinetics (PK) and Pharmacodynamics (PD)

Blood samples for determination of serum ravelizumab concentrations and PD assessment (free C5) were collected before and after study intervention administration at the time points specified in the assessment schedule. The actual date and time (24-hour clock) of each sample was recorded.

Day 1 baseline PK and PD blood samples will be collected predose within 30 minutes prior to administration of the study intervention at the visit specified in the assessment schedule. Day 1 predose blood samples may be drawn prior to dose administration through venous access created for dose infusion.

Postdose PK and PD blood samples were collected within 30 minutes after completion of the study intervention infusion. Postdose blood samples were drawn from the participant's opposite, non-infused arm. Samples may be collected at any visit after Day 1. In the case of unscheduled visits, PK and PD blood samples were collected as soon as possible.

Information about the study intervention concentration that could potentially unblind the study was not reported to the study sites or blinding personnel until the study was unblinded.

Genetics were not evaluated in this study.

Blood (serum and plasma) samples for exploratory assessments will be collected from all participants at designated time points in the assessment schedule. Biomarkers may include, but are not limited to, assessments of: (1) activation of the complement pathway (e.g., soluble C5b-9 [sC5b-9]), (2) endothelial injury and/or activation (e.g., thrombomodulin [TM]), (3) vascular inflammation (e.g., abscess tumor necrosis factor receptor I [TNF-RI]), and (4) inducers of cell cycle arrest (e.g., tissue metalloproteinase inhibitor-2 [TIMP-2]).

Urine samples for exploratory assessments were collected from all participants at designated time points in the activity schedule. Biomarkers included, but were not limited to, assessments of: (1) activation of the cytokine pathway (e.g., sC5b-9), and (2) renal injury (e.g., neutrophil-associated lipocalin [NGAL]).

Retain blood and urine samples from exploratory biomarkers, PK, PD, and immunogenicity for additional assessments (e.g., related to the study intervention target, disease process, pathways relevant to the disease state, other complement-related diseases, and/or the mechanism of action of ravulizumab). Retain samples for no longer than 5 years after termination of study or such other time as required by local authorities.

The Quality of Life Scale was completed by participants at the visits specified in the assessment schedule prior to other study procedures.

Participants in both cohorts were administered the following validated quality of life scale: The Kidney Disease Quality of Life Instrument-36 Items (KDQOL-36) (Section 10.7) (36-item short-form survey) is a widely used measure for dialysis patients. Participants are asked to answer questions about their health, kidney disease, and the impact of kidney disease on their daily life.

The European Quality of Life Group 5 Dimensions 5 Levels (EQ-5D-5L) (Section 10.7) is a self-assessment standardized instrument used to measure health-related quality of life and has been widely used for a wide range of health conditions. The EQ 5D 5L is a 5-scale participant-reported end-point instrument measuring pain/discomfort, mobility, self-care, usual activities, and anxiety/depression.

The Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale, version 4.0, is a 13-item questionnaire that assesses self-reported fatigue and its impact on daily activities and functioning over the previous 7 days.

Healthcare resource utilization related to medical encounters was collected for all participants throughout the primary assessment period. Protocol-mandated procedures, tests, and experiences were excluded. Hospitalization from admission to discharge (including admission date, discharge date, and dates of ICU stay and transfer to another inpatient unit). Renal replacement therapy (KRT): type/modality, frequency, start and stop dates, and reason for start/stop. Duration of mechanical ventilation (date and start/stop times). Discharge destination (e.g., home, rehabilitation facility, hospice facility).

Hospital readmission (ER or inpatient admission; elective outpatient surgery performed in a hospital setting was not considered a readmission). Primary reasons were assessed as: preoperative (usually primary reason if present), cardiovascular event not requiring reoperation (e.g., MI, stroke, heart failure, arrhythmia), AKI, or other. Hospitalization from readmission to discharge, including date of visit to the ER, inpatient admission, discharge, and dates of ICU admission and transfer to another inpatient unit. Specific reasons for readmission were reported as AEs/SAEs.

Additional data collected (e.g., concomitant medications and outpatient diagnostic and treatment procedures) may allow for exploratory economic analyses.

Other exploratory endpoints included: (1) AKI within 7 days after sCysC-based CPB, (2) highest AKI stage according to KDIGO criteria, and (3) absence of severe AKI (KDIGO stage 2 or 3).

The minimum follow-up for safety was 90 days after dosing of the study intervention (Day 1, Visit 2). Participants in this study received a single weight-based dose of the study intervention and underwent cardiac surgery with CPB within 1-7 days of dosing (maximum interval between dosing and cardiac surgery with CPB was 15 days if there was an unanticipated delay in surgery) and underwent all study visits and procedures as outlined in the Assessment Schedule until the Day 90 Visit (Visit 9). The timing of postoperative (post-CPB) visits on Days 3, 7, 15, 30, 60, and 90 was based on the CPB date, with Day 1 Post-CPB defined as the day after the participant came off CPB. However, additional circumstances may arise during the conduct of the study: If a participant received a study intervention and did not undergo cardiac surgery, or surgery was delayed more than 15 days after dosing, the participant had all subsequent study visits and procedures as outlined in the Assessment Schedule through the Day 90 visit, with the timing of visits based on the dosing date (Day 1, Visit 2). If a participant was randomized but not dosed, the participant had all subsequent study visits and procedures as outlined in the Assessment Schedule through the Day 90 visit, with the timing of visits based on the randomization date (i.e., Day 1, Visit 2). If a participant withdrew, a decision to discontinue early (ED) was made, and Visit 9 was immediately performed.

Anti-drug antibodies (ADAs) to ravlizumab were assessed in serum samples collected from all patients according to the assessment schedule. In addition, serum samples were collected at the last visit from participants who discontinued the study intervention or withdrew from the study.

Screen serum samples for antibodies that bind to Ravelizumab and report titers for confirmed positive samples. Additional analyses may be performed to further characterize the immunogenicity of Ravelizumab.

Detection and characterization of antibodies to Ravelizumab were performed using a validated assay. Ravelizumab serum concentrations were evaluated on samples collected for detection of antibodies to Ravelizumab to assess the effect of ADA on the drug concentration curve in ADA-positive patients. ADA-positive samples were further characterized for antibody titer and the presence of neutralizing antibodies.

ADA variables included the incidence and titer of ADA response categories over the duration of the study as follows. ADA response category definitions and titer thresholds were provided in the Statistical Analysis Plan (SAP). ADA response categories were ADA negative and ADA positive. Participants who were ADA positive were categorized as follows: pre-existing immune reactivity or treatment-emergent ADA response. 11. Statistical Considerations

The primary hypothesis to be tested in this study was that revlizumab is superior to placebo in reducing the risk of MAKE events 90 days after CPB (MAKE90): H ₀ : p ₁ ≥ p ₀ H ₁ : p ₁ ＜ p ₀ where p ₁ and p ₀ represent the probability of experiencing a MAKE90 event in the revlizumab group and the placebo group, respectively.

The treatment effect based on the MAKE90 endpoint was estimated by the difference in the proportion of participants who experienced MAKE90, regardless of any IEs, between the revlizumab and placebo groups. A negative difference indicated a beneficial treatment effect of revlizumab.

In the event that the null hypothesis for the primary endpoint was rejected, the following key secondary hypotheses were tested sequentially in the following hierarchical order. Revilizumab was superior to placebo in the proportion of participants free of CSA AKI at day 90 after CPB. Revilizumab was superior to placebo in the proportion of participants free of severe CSA-AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 7 days after CPB. Revilizumab was superior to placebo in the proportion of participants free of severe AKI (RIFLE injury or failure criteria) based on the highest sCr observed within 30 days after CPB. Revilizumab was superior to placebo in the proportion of participants free of any severe AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 30 days after CPB. Ravelizumab was superior to placebo in the proportion of participants who did not meet any RIFLE failure criteria based on the highest sCr observed within 30 days after CPB. Ravelizumab was superior to placebo in the proportion of participants who died from any cause from randomization to day 90 after CPB.

Sample size estimates were based on two-proportion differences using the normal approximation to compare treatment differences between the revlizumab and placebo groups in the proportion of participants who experienced a MAKE event within 90 days after CPB. A sample size of 736 (368 participants per treatment group) provided 90% power to detect a statistically significant treatment difference of 10% in the proportion of participants who had a MAKE within 90 days after CPB at a 2-sided significance level of 0.05, assuming a MAKE proportion of 25% in the placebo group and 15% in the revlizumab group, with a dropout rate of approximately 10%. The assumption of a 25% MAKE90 rate in the placebo group was based on recent interventional and observational trials as described below.

Recent intervention trials aimed at reducing CSA-AKI have reported 9% to 10% of placebo-treated participants achieving the MAKE endpoint at day 30 (see, e.g., Meersch M et al., Intensive Care Med . 2017;43(11):1551-61; Jacob KA et al., J. Am. Soc. Nephrol. 2015;26(12):2947-51; Venugopal H et al., Kidney360. 2020;1(6):530-3) and 13% to 22% at day 90 (see, e.g., Thielmann M et al., Circulation . 2016;43(11):1551-61). 2021;144(14):1133-1144; and Meersch M et al., Intensive Care Med . [Intensive Care Med] 2017;43(11):1551-61). These studies included varying proportions of participants with CKD (8%-47%). A post hoc analysis of the subgroup with dexamethasone-induced CKD in the Heart Surgery Study (preoperative eGFR < 60 mL/min/1.73m2) reported a MAKE30 of 16.5% in the placebo group (see Venugopal H et al., Kidney360. [ Kidney360 ] 2020;1(6):530-3). Because these studies did not specifically enroll patients with CKD, it is expected that the studies would have a higher placebo rate, as they enrolled individuals who were at increased risk for AKI due to pre-existing CKD and who were predicted to have an increased risk of renal failure using the STS risk calculator.

There are limited data from other trials on the frequency of MAKE (or its individual component outcomes) in patients with preexisting CKD. Therefore, estimates of individual MAKE events were derived from observational studies as well as data from this trial to inform the placebo rate assumption of 25% for the current study: KRT 7% to 10%: Interventional trials reported KRT in 6.5% to 7.5% of participants who received placebo (see, e.g., Thielmann M et al., Circulation . 2021;144(14):1133-1144; and Meersch M et al., Intensive Care Med . 2017;43(11):1551-61)). Observational studies from multiple healthcare systems have reported postoperative KRT in 7% to 30% of patients with preexisting CKD (see, e.g., Wu VC, Kidney Int. 2011;80(11):1222-1230; Cho JS et al. , J . Thorac. Cardiovasc. Surg . 2021;161(2):681-8.e3; and Lau D et al., J. Thorac. Cardiovasc. Surg . 2021;162(3):880-7). Given the exclusive recruitment of participants with CKD, it is expected that at least 7% of participants will require KRT. The use of the STS renal failure risk calculation thresholds for inclusion in this study was also expected to enrich participants at highest risk for requiring KRT, particularly among participants with pre-existing CKD stage 3a.

Mortality rate 4% to 7%: Interventional trials have reported a mortality rate of 2% to 7% within 90 days after CPB (see, e.g., Thielmann M et al., Circulation . 2021;144(14):1133-1144; and Meersch M et al., Intensive Care Med . 2017;43(11):1551-61); Whitlock RP et al., Lancet . 2015;386(10000):1243-53; and Dieleman JM et al., JAMA . 2012;308(17):1761-7). In observational studies, AKI has been independently associated with the risk of death after CPB, with the highest risk in patients requiring acute KRT (see, e.g., Lau D et al., J. Thorac. Cardiovasc Surg . 2021;162(3):880-7; and Matsuura R et al., Sci Rep . 2020;10(1):6490). In addition, the addition of AKI to pre-existing CKD increases the risk of death after cardiac surgery by up to 11% (Cho 2021). Therefore, because of the exclusive enrollment of patients with CKD, an overall mortality rate of approximately 5% to 6% was expected.

SKD 17% to 25%: Using sCr or changes in eGFR based on sCr, observational studies have reported 19% to 22% of the CKD population to have SKD 3 months after CPB (see, e.g., Wu VC, Kidney Int. 2011;80(11):1222-1230; Xu J et al. , BMC Nephrol. 2019;20(1):427; Matsuura R et al., Sci Rep. 2020;10(1):6490); and Cho JS et al., J. Thorac. Cardiovasc. Surg. 2021;161(2):681-8.e3). AKI superimposed on CKD is the greatest risk factor for SKD, with 20% to 30% not returning to baseline renal function within 90 days (Cho 2021, Wu, 2011, Matsuura 2020). Data from these interventional trials are limited and cannot directly inform SKD rates in participants with pre-existing CKD. Recent trials have reported SKD rates of 7% to 12% in control/placebo groups without sufficient enrichment for CKD (see, e.g., Thielmann M et al., Circulation . 2021;144(14):1133-1144; and Meersch M et al., Intensive Care Med . 2017;43(11):1551-61). The dedicated enrollment of participants with CKD was expected to increase the proportion of participants classified as SKD at 90 days compared with other CSA-AKI trials.

MAKE90 20% to 30%: The frequency of individual events is not additive because individual participants can usually meet the criteria of > 1 event in 90 days. Recent clinical trials (see, e.g., Thielmann M et al., Circulation . 2021;144(14):1133-1144; and Meersch M et al., Intensive Care Med . 2017;43(11):1551-61) reported that approximately 30% of patients experienced more than 1 MAKE (KRT, death, SKD). Assuming a similar pattern in the current study, the expected proportion of participants in the placebo group who would achieve the MAKE endpoint at 90 days was estimated to be 20% to 30% based on a synthesis of the various data sources summarized here; the assumed placebo rate for this study was 25%.

The population sets used for analysis in this study are defined in Table 9. [ Table 9 ] : Analysis populations crowd describe Intent-to-treat (ITT) All participants who were randomly assigned to receive the research intervention. Participants were analyzed randomly. Modified intention-to-treat (mITT) All randomized participants who received the complete weight-based study intervention dose and underwent CPB surgery within 15 days of dosing were included in the randomized analysis. Per-Protocol Set (PPS) All participants in the mITT who did not have an important protocol deviation. Participants were analyzed randomly. All prospectively defined protocol deviations were defined in SAP before the clinical database was locked. Postoperative Set (POS) All participants in the mITT with stable preoperative renal function (sCr remained <1.5 times baseline before CPB [visit 3], no KRT). Participants were randomly analyzed. Security Set (SS) All randomized participants who received the study intervention. Participants were analyzed based on the study intervention they actually received. PK Analysis Set (PKAS) All ravlizumab-treated patients with at least 1 available post-baseline PK concentration. PD Analysis Set (PDAS) All randomized participants who received study intervention and had at least 1 postdose PD measurement. ADA Analysis Set (AAS) All randomized participants who received ravulizumab and had at least 1 reportable post-dose ADA outcome. Participants were analyzed according to the study intervention they actually received. Abbreviations: ADA = antidrug antibodies; CPB = cardiopulmonary bypass; KRT = renal replacement therapy; PD = pharmacodynamics; PK = pharmacokinetic; SAP = statistical analysis plan; sCr = serum creatinine.

Evaluable PK, PD, and ADA data were defined as non-missing results generated from samples that met sample integrity requirements during sample collection, storage, shipment, and bioanalysis.

In general, descriptive statistics (n, mean, median, standard deviation, first and third quartiles, minimum, and maximum) are provided by treatment group and visit for each quantitative variable, and frequencies and percentages are provided by treatment group and visit for each qualitative variable. Graphical displays are provided when appropriate. Baseline was defined as randomization day 1 before the administration of the study intervention unless otherwise stated below. Final analysis and study unblinding occurred after the last enrolled participant completed the Day 90 visit or withdrew early. Analyses were performed using SAS® software, version 9.4 or higher.

The primary efficacy analysis was based on the intention-to-treat (ITT) analysis set. The primary endpoint was a MAKE event at 90 days after CPB (MAKE90), defined as meeting at least 1 of the following criteria: (1) a ≥ 25% decrease in eGFR from baseline at day 90 after CPB, (2) the occurrence of KRT by day 90 after CPB, or (3) death from any cause by day 90 after CPB. Baseline and post-baseline eGFR were calculated from sCysC using the CKD-EPI formula. Baseline eGFR was based on the mean of sCysC collected during the screening period and on day 1 before the administration of the study intervention.

The observed proportion of participants undergoing MAKE 90 is reported by treatment group. Treatment effects on MAKE90 endpoints were estimated using the continuity-corrected Cochran-Mantel-Haenszel (CMH) method with adjustment for stratified variables. For missingness of MAKE90 endpoints due to partial or complete missingness of individual components, missingness of KRT initiation or death was imputed as a non-event, and missingness of eGFR was handled by multiple imputation from mixed models with repeated measures (MMRM), assuming missing at random by treatment group and then dichotomized into binary variables. The MMRM model included baseline, CKD stage, surgery type, visit, treatment group, and treatment group with visit interactions as fixed effects and participant as a random effect, using all available data. Rubin's rule was used to combine the results to generate multiple imputation point estimates and standard errors. If the distribution of the CMH test statistic deviated severely from normality, a Wilson-Hilferty transformation was applied before combining using Rubin's rule. P values and 2-sided 95% confidence intervals (CIs) for MAKE90 treatment differences are reported.

Sensitivity analyses were performed to assess the robustness of the results to the missing data estimation methods. Missing data from MAKE90 were imputed multiple times by treatment group based on a logistic regression model. The logistic model included CKD stage, surgery type, visit, and treatment group with visit interactions as covariates. The CMH test was applied in the same way as for the primary analysis along with the Rubin rule. If the CMH test statistic deviated severely from the normality assumption, the Wilson-Hilferty transformation was applied.

A secondary sensitivity analysis was performed based on multiple imputation from a jump-to-reference (J2R) model. For participants who discontinued the study without any further follow-up data, any missing values after discontinuation were imputed under the assumption that their outcome would be similar to that in the placebo group with similar baseline characteristics. CMH tests were performed in a similar manner as in the primary analysis.

In addition, individual MAKE 90 components were analyzed. The proportion of participants with a ≥ 25% decrease in eGFR (using the CKD-EPI formula of sCysC) from baseline to day 90 after CPB, or to initiation of KRT on day 90 after CPB, or to death from any cause on day 90 after CPB were summarized by treatment group and visit. Point estimates of the treatment difference and associated 2-sided 95% CIs were given by visit using the CMH method, adjusting for stratification factors.

In addition to the primary treatment strategy measure, additional supplementary measures using the ITT population or other populations (ie, modified intention-to-treat [mITT], per-protocol set [PPS], and postoperative set [POS]) were defined to assess the robustness of the effect of the primary measure. Details are provided in the SAP.

Secondary efficacy analyses were based on the ITT analysis set. A sequential testing procedure was performed for key secondary endpoints in the following order: A.  Freedom from CSA-AKI at day 90 after CPB, defined as the absence of AKI within the first 7 days after CPB or resolution of AKI by day 90 after CPB (stage 0); B.  Freedom from severe CSA-AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 7 days after CPB; C.  Freedom from any severe AKI (RIFLE injury or failure criteria) based on the highest sCr observed within 30 days after CPB; D.  Freedom from any severe AKI (KDIGO stage 2 or 3) based on the highest sCr observed within 30 days after CPB; and E.  Freedom from any RIFLE failure criteria based on the highest sCr observed within 30 days after CPB. F.   All-cause mortality from randomization to 90 days after CPB

The highest observed sCr was from central laboratory samples collected at designated study visits from daily local laboratory sCr results at any time during the first 30 days. The baseline sCr used to define AKI was based on the mean of the sCr collected during the screening period and on day 1 before study intervention administration. Specifically, key secondary endpoints were tested against the same significance level as the primary endpoint when the null hypothesis for the primary endpoint was rejected, and sequential testing was terminated when any null hypothesis failed to be rejected.

Analyses of key secondary endpoints were identical to the primary analyses. The observed proportion of participants meeting each key secondary endpoint was summed by treatment group.

To estimate treatment effects in key secondary endpoints, missing data due to premature withdrawal and all other events were imputed by last observation carried forward (LOCF) when applicable or imputed as not achieving that endpoint otherwise. Point estimates and associated 2-sided 95% CIs were estimated using the CMH method adjusted for stratification factors.

If the test for the primary endpoint showed statistical significance, each of the above 2 to 5 key secondary endpoints was examined for association with the following clinical outcomes: death, KRT initiation, readmission, KRT duration (days), ICU duration (days), ventilation duration (days), and hospital duration (days).

For binary clinical outcomes including death, KRT initiation, and readmission, 2-by-2 contingency tables of clinical outcomes and key secondary endpoints were presented by treatment group and overall. Chi-square tests were performed to test the association between two variables.

For continuous clinical outcomes, summary statistics were provided by key secondary endpoint category, treatment group, and overall. Linear regression was applied with key secondary endpoint and treatment group as covariates.

MAKE90 was determined using sCr, similar to the primary endpoint MAKE90, which was determined based on the CKD-EPI formula using sCysC. In addition, MAKE30 and MAKE60 endpoints were determined similarly. The proportion of participants who experienced MAKE at 30, 60, and 90 days after CPB were summarized by treatment group and visit. Point estimates of the treatment difference and the associated p-values and 2-sided 95% CIs were given using the CMH method, adjusting for stratification factors.

In addition, individual MAKE components were analyzed. The proportion of participants with a ≥ 25% decrease in eGFR from baseline to days 30, 60, and 90 after CPB, or to initiation of KRT at days 30, 60, and 90 after CPB, or to death from any cause at days 30, 60, and 90 after CPB were summarized by treatment group and visit. Point estimates of the treatment difference and the associated 2-sided 95% CIs were given by visit using the CMH method, adjusting for stratification factors.

Additional analyses may be explored to examine the treatment effect of each individual component of MAKE at days 30, 60, and 90 after CPB.

The proportion of participants who experienced KRT or died by day 30, 60, and 90 after CPB were summarized by treatment group. Point estimates and associated 2-sided 95% CIs were provided using the CMH method, adjusting for stratification factors.

The proportion of participants with the highest stage of CSA-AKI observed within the first 3 and 7 days after CPB using modified KDIGO criteria was summarized by treatment group.

The proportions of participants free of CSA-AKI and free of any AKI at the scheduled visit were summarized by treatment group and visit. Point estimates and associated 2-sided 95% CIs were estimated using the CMH method, adjusting for stratification factors.

The proportions of participants who experienced CSA-AKI within 7 days after CPB and had AKI recovery (complete or partial), AKI improvement, AKI stabilization, or AKI progression at days 15, 30, 60, and 90 after CPB were summarized by treatment group and visit. Point estimates and associated 2-sided 95% CIs were estimated using the CMH method with adjustment for stratification factors, if appropriate.

Duration of initial hospitalization and ICU stay (days) was calculated for each participant based on the date of discharge minus the date of admission, where initial hospitalization and ICU stay referred to admission for CPB procedures. For patients on ventilators, duration of ventilator use (days) was calculated based on the date of ventilator release minus the date of ventilator onset. For patients receiving KRT, duration of KRT (days) was calculated based on the date of KRT last minus the date of KRT start.

Descriptive statistics were used to summarize the duration of each treatment group. They included the number of observations in each treatment group, mean, standard deviation, median, minimum, maximum, interquartile range (IQR), first quartile value, and third quartile value.

Readmission rates (all-cause or AKI-related) to day 30 and 90 after CPB were summarized by treatment group and visit. Point estimates and associated 2-sided 95% confidence intervals were estimated using the CMH method with adjustment for stratification factors, if appropriate.

The following quality-of-life assessments were summarized by treatment group at baseline and each postbaseline time point using descriptive statistics of observed values and changes from baseline: FACIT-Fatigue, EQ-5D-5L, and KDQOL-36.

Changes from baseline were also summarized for each treatment group from the MMRM analysis; no formal treatment comparisons were performed. Point estimates and two-sided 95% CIs for the mean differences in these measure scores are presented.

Analyses of exploratory biomarker data are described in separate analysis plans and may be summarized after study completion.

The multiple testing procedure involves testing of a primary endpoint followed by prespecified hierarchical testing of key secondary endpoints. Statistical significance is assessed in the hypothesized order. Secondary endpoints are tested in a fixed order only if the primary endpoint is statistically significant. Key secondary endpoints are tested further down the hierarchy only if the test on the preceding secondary endpoint is statistically significant.

A re-estimate of the sample size was performed at the second interim analysis, when approximately 50% of the participants had completed the primary assessment period. Conditional power based on the observed treatment effect was calculated to determine whether enrollment should continue to achieve the planned or increased sample size. The primary end point was tested in the final analysis when all enrolled participants had completed the primary assessment period at a one-sided significance level of 0.025. If the test of the primary end point was statistically significant in the final analysis, the statistical significance of the key secondary end points was assessed in a fixed order.

Under this prespecified multiple testing procedure and hierarchical testing strategy, the overall type I error was controlled at a one-sided 0.025 multiplicity level for the primary and key secondary endpoints. Other planned interim analyses were not at risk of type I error expansion at the 30% sample size used for early futility assessments.

Safety was assessed based on AEs, clinical laboratory findings, and vital sign findings. All safety analyses were performed on the safety set.

The incidence of treatment-emergent adverse events (TEAEs), TEAEs leading to study withdrawal, and treatment-emergent serious adverse events (TESAEs) were summarized by treatment group. TEAEs were defined as those AEs with an onset from the start of the study intervention to 90 days after the study intervention or a worsening of severity of an ongoing event. All AEs were coded using the Medical Dictionary for Regulatory Activities (MedDRA), version 24.1 or higher, and were summarized by system organ class (SOC) and preferred term overall, by severity, and by relationship to the study intervention. A detailed listing of TEAEs, TESAEs, relevant TEAEs, and TEAEs leading to study withdrawal by participant was provided. Participants with multiple AEs within a category (e.g., overall, SOC, preferred) were counted once in that category. For the severity table, the most serious event for the participant within the category was counted. AESI (e.g., meningococcal infection) were analyzed similarly.

Abnormal physical examination findings were classified as AEs and analyzed accordingly.

Vital signs were summarized descriptively by treatment group at baseline and postbaseline time points and for changes from baseline.

Observed values and changes from baseline for clinical chemistry, hematology, and urinalysis were summarized descriptively by treatment group at baseline and at each postbaseline time point. For laboratory results that were categorized as normal, low, or high based on normal range values, changes from baseline were summarized for all study visits.

PK and PD analyses included all data in the PK analysis set and PD analysis set, respectively.

Construct mean serum ravulizumab concentration-time curves. Serum concentration-time curves for individual participants are also available. Descriptive statistics for serum concentration data at each sampling time were calculated where appropriate.

The PD effect of ravulizumab was assessed by evaluating the absolute value and change in serum free C5 concentration over time and the percentage change from baseline, as appropriate. Descriptive statistics of PD data were calculated for each sampling time, as appropriate.

All anti-drug antibody (ADA) analyses were performed on the ADA Assay Set (AAS).

The incidence of ADA response categories was summarized as absolute incidence (n) and percentage of all participants (%) in the ravlizumab group at days 30 and 90. Confirmed antibody-positive samples were further evaluated for antibody titer and the presence of neutralizing antibodies. The maximum ADA titer level in ADA-positive participants was listed and summarized as absolute incidence (n) and percentage of all participants (%).

Immunogenicity variables can be studied in relation to effects on drug exposure, efficacy, and safety.

Subgroup analyses of the primary and key secondary endpoints were performed in the following subsets of participants: (1) participants with different CKD stages at baseline, (2) participants with different types of surgery during CPB, (3) participants in the age groups 18 to 60 years, 61 to 75 years, and > 75 years, (4) participants with a baseline body weight of ≥ 30-59 kg, 60-99 kg, and ≥ 100 kg, (5) participants with the following proteinuria levels (measured as albumin-to-creatinine ratio [ACR]) at baseline (KDIGO 2013): < 30 mg albumin/g creatinine, ≥ 30 to < 300 mg albumin/g creatinine, and ≥ 300 mg albumin/g creatinine, and (6) participants with and without diabetes.

Two interim analyses were planned to be performed by an independent data monitoring committee (DMC) after approximately 30% (approximately 220 participants) and 50% (approximately 368 participants) of the randomized participants had completed the primary assessment period (i.e., the 90-day post-CPB visit). The purpose of the first interim analysis was to assess early stopping for futility, and the second interim analysis was planned to perform a sample size re-estimate.

For futility and sample size re-estimate assessments, conditional power for the primary endpoint analysis was calculated at the interim analysis using the observed trend. If the conditional power was less than 20% at the first interim analysis, the study was considered to be futility and stopped early. However, the futility criteria were non-binding. In other words, if the primary endpoint met the pre-specified futility criteria at the first interim analysis, the study could continue without stopping for futility.

For the sample size re-estimate at the second interim analysis, the study sample size was increased if the conditional power fell into the promising region (0.5, 0.9). This promising region was chosen to ensure that the routine analysis at the end of the study would not inflate the study type I error at the planned maximum sample size increase. To prevent potential unblinding of interim analysis results during the sample size re-estimate procedure, a step function was used to guide the sample size increase if the interim analysis results fell into the pre-specified promising region. Details of the interim analysis were recorded in the interim statistical analysis plan (iSAP) before the interim analysis. 12. Clinical laboratory tests

Unless otherwise noted, the tests detailed in Table 10 were performed by the study site laboratory. Local laboratory results are required only if central laboratory results are not available in a timely manner for eligibility, study intervention administration, and/or response evaluation. If local specimens are required, it is important that the specimens for central analysis are obtained at the same time. In addition, if local laboratory results are used to make eligibility or study intervention decisions or response evaluations, the results must be available in the participant's original file. Serum creatinine tests performed locally as standard of care within the first 30 days after CBP were reviewed. The highest observed result was reported on the CRF. Additional laboratory testing may be performed at any time during the study as determined by the needs of the Investigator or as required by local regulations. WOCBP can be enrolled only after a negative serum pregnancy test result at screening. Perform additional pregnancy testing as indicated in the evaluation schedule. [ Table 10 ] : Laboratory evaluation required by the program Laboratory evaluation Parameters Hematology HemoglobinHematocritPlatelet countRBC countRBC indices: • Average red blood cell volume • Distribution widthWBC count and classification: • Neutrophils • Lymphocytes • Monocytes • Eosinophils • Baclofen Clinical Chemistry Alanine transaminase Albumin Alkaline phosphatase Aspartate transaminase Bicarbonate Blood urea nitrogen Calcium Chloride Creatinine (sCr) Cysteine C (sCysC) Glucose, nonfasting Potassium Sodium Total bilirubin and direct bilirubin Total protein High-sensitivity creatin T (hs-cTnT) Uric acid Urine Chemistry Urine albumin concentration Urine creatinine concentration Albumin/creatinine ratio (UACR) PK/PD Serum PK Serum PD (free C5) Immunogenicity ADA and NAb Exploratory biomarkers (blood and urine) Assessments may include, but are not limited to, biomarkers of complement activation (e.g., soluble C5b-9), endothelial damage (e.g., plasma thrombomodulin [TM]), vascular inflammation (e.g., TNF-RI), cell cycle arrest (TIMP-2), and renal damage (e.g., neutrophil-associated lipocalin [NGAL]). Other tests • Serum FSH and estradiol (as needed to confirm WOCBP status) • Serum human chorionic gonadotropin pregnancy test (as needed for WOCBP) Abbreviations: ADA = anti-drug antibodies; Ba = complement factor B; C5 = complement component 5; NAb = neutralizing antibodies; PD = pharmacodynamics; PK = pharmacokinetic; RBC = red blood cells; WBC = white blood cells; WOCBP = women of childbearing potential13. Exploratory Biomarkers

Blood and urine samples are collected for exploratory assessments related to revlizumab or CSA-AKI and related diseases. These samples may also be used for further exploratory development of assays related to revlizumab's mechanism of action, disease process, and/or pathways associated with the CSA-AKI disease state. Results of biomarker analyses may be reported in the CSR or later in a separate study summary. 14. COVID-19 Vaccine Risk Assessment

There is currently no information available evaluating the safety and efficacy of COVID-19 vaccines in participants treated with Ravelizumab. Based on the mechanism of action of Ravelizumab, it is unlikely that Ravelizumab administration will diminish the immune response to COVID 19 vaccines (and therefore the efficacy of vaccination). It is also unlikely that COVID-19 vaccination will affect the mechanism of action of Ravelizumab.

Vaccinations may further activate complements. Therefore, participants with complement-mediated disease may experience exacerbations of their underlying disease. Therefore, subjects should be closely monitored for symptoms of disease after recommended vaccinations. Because vaccines activate complements, if possible, consider vaccination soon after administration when underlying complement-mediated disease is clinically controlled and when systemic C5 inhibitor concentrations (and subsequent complement blockade) are relatively high. Local and national guidelines should be consulted for recommendations regarding COVID-19 vaccinations.

The identified potential risks and mitigating measures for COVID-19 vaccination rollout are provided in Table 11. [ Table 11 ] : Potential operational risks and mitigation measures due to COVID-19 vaccines Risk Type Data Summary / Risk Principle Mitigation strategies Potential Risks Data quality and integrity Missing data due to scheduled COVID-19 vaccinations or side effects of the COVID-19 vaccine could impact study visit schedules and increase missed visits and/or participant discontinuations, inadvertently leading to missing data (e.g., for protocol-mandated procedures). Obtain specific information in the CRF explaining why data are missing (e.g., missed study visit due to COVID-19 vaccine appointment or COVID-19 vaccine side effects). Abbreviations: COVID-19 = Coronavirus Disease 2019; CRF = Case Report Form. Serial Summary SEQ ID NO:1 GYIFSNYWIQ SEQ ID NO:2 EILPGSGSTEYTENFKD SEQ ID NO:3 YFFGSSPNWYFDV SEQ ID NO:4 GASENIYGALN SEQ ID NO:5 GATNLAD SEQ ID NO:6 QNVLNTPLT SEQ ID NO:7 QVQLVQSGAE VKKPGASVKV SCKASGYIFS NYWIQWVRQA PGQGLEWMGE ILPGSGSTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SS SEQ ID NO:8 DIQMTQSPSS LSASVGDRVT ITCGASENIY GALNWYQQKP GKAPKLLIYG ATNLADGVPS RFSGSGSGTD FTLTISSLQP EDFATYYCQN VLNTPLTFGQ GTKVEIK SEQ ID NO:9 ASTKGPSVFP LAPCSRSTSE STAALGCLVK DYFPEPVTVS WNSGALTSGV HTFPAVLQSS GLYSLSSVVT VPSSNFGTQT YTCNVDHKPS NTKVDKTVER KCCVECPPCP APPVAGPSVF LFPPKPKDTL MISRTPEVTC VVVDVSQEDP EVQFNWYVDG VEVHNAKTKP REEQFNSTYR VVSV LTVLHQ DWLNGKEYKC KVSNKGLPSS IEKTISKAKG QPREPQVYTL PPSQEEMTKN QVSLTCLVKG FYPSDIAVEW ESNGQPENNY KTTPPVLDSD GSFFLYSRLT VDKSRWQEGN VFSCSVMHEA LHNHYTQKSL SLSLGK SEQ ID NO:10 QVQLVQSGAE VKKPGASVKV SCKASGYIFS NYWIQWVRQA PGQGLEWMGE ILPGSGSTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SSASTKGPSV FPLAPCSRST SESTAALGCL VKDYFPEPVT VSWNSGALTS GVHTFPAVLQ SSGLYSLS SV VTVPSSNFGT QTYTCNVDHK PSNTKVDKTV ERKCCVECPP CPAPPVAGPS VFLFPPKPKD TLMISRTPEV TCVVVDVSQE DPEVQFNWYV DGVEVHNAKT KPREEQFNST YRVVSVLTVL HQDWLNGKEY KCKVSNKGLP SSIEKTISKA KGQPREPQVY TLPPSQEEMT NQVSLTCLVK GFYPSDIAVE WESNGQPENN YKTTPPVLDS DGSFFLYSRL TVDKSRWQEG NVFSCSVMHE ALHNHYTQKS LSLSLGK SEQ ID NO:11 DIQMTQSPSS LSASVGDRVT ITCGASENIY GALNWYQQKP GKAPKLLIYG ATNLADGVPS RFSGSGSGTD FTLTISSLQP EDFATYYCQN VLNTPLTFGQ GTKVEIKRTV AAPSVFIFPP SDEQLKSGTA SVVCLLNNFY PREAKVQWKV DNALQSGNSQ ESVTEQDSKD STYSLSST LT LSKADYEKHK VYACEVTHQG LSSPVTKSFN RGEC SEQ ID NO:12 QVQLVQSGAE VKKPGASVKV SCKASGHIFS NYWIQWVRQA PGQGLEWMGE ILPGSGHTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SS SEQ ID NO:13 ASTKGPSVFP LAPCSRSTSE STAALGCLVK DYFPEPVTVS WNSGALTSGV HTFPAVLQSS GLYSLSSVVT VPSSNFGTQT YTCNVDHKPS NTKVDKTVER KCCVECPPCP APPVAGPSVF LFPPKPKDTL MISRTPEVTC VVVDVSQEDP EVQFNWYVDG VEVHNAKTKP REEQFNSTYR VV SLSLGK SEQ ID NO:14 QVQLVQSGAE VKKPGASVKV SCKASGHIFS NYWIQWVRQA PGQGLEWMGE ILPGSGHTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SSASTKGPSV FPLAPCSRST SESTAALGCL VKDYFPEPVT VSWNSGALTS GVHTFPAVLQ SSGLYSLSSV VTVPSSNFGT QTYTCNVDHK PSNTKVDKTV ERKCCVECPP CPAPPVAGPS VFLFPPKPKD TLMISRTPEV TCVVVDVSQE DPEVQFNWYV DGVEVHNAKT KPREEQFNST YRVVSVLTVL HQDWLNGKEY KCKVSNKGLP SSIEKTISKA KGQPREPQVY TLPPSQEEMT KNQVSLTCLV KGFYPSDIAV EWESNGQPEN NYKTTPPVLD SDGSFFLYSR LTVDKSRWQE GNVFSCSVLH EALHSHYTQK SLSLSLGK SEQ ID NO:15 ASTKGPSVFP LAPCSRSTSE STAALGCLVK DYFPEPVTVS WNSGALTSGV HTFPAVLQSS GLYSLSSVVT VTSSNFGTQT YTCNVDHKPS NTKVDKTVER KCCVECPPCP APPVAGPSVF LFPPKPKDTL YITREPEVTC VVVDVSHEDP EVQFNWYVDG MEVHNAKTKP REEQFNSTFR VV SLSPGK SEQ ID NO:16 QVQLVQSGAE VKKPGASVKV SCKASGYIFS NYWIQWVRQA PGQGLEWMGE ILPGSGSTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SSASTKGPSV FPLAPCSRST SESTAALGCL VKDYFPEPVT VSWNSGALTS GVHTFPAVLQ SSGLYSLS SV VTVTSSNFGT QTYTCNVDHK PSNTKVDKTV ERKCCVECPP CPAPPVAGPS VFLFPPKPKD TLYITREPEV TCVVVDVSHE DPEVQFNWYV DGMEVHNAKT KPREEQFNST FRVVSVLTVV HQDWLNGKEY KCKVSNKGLP APIEKTISKT KGQPREPQVY TLPPSREEMT KNQVSLTCLV KGFYPSDIAV EWESNGQPEN NYKTTPPMLD SDGSFFLYSK LTVDKSRWQQ GNVFSCSVMH EALHNHYTQK SLSLSPGK SEQ ID NO:17 GASENIYHALN SEQ ID NO:18 EILPGSGHTEYTENFKD SEQ ID NO:19 GHIFSNYWIQ SEQ ID NO:20 QVQLVQSGAE VKKPGASVKV SCKASGHIFS NYWIQWVRQA PGQGLEWMGE ILPGSGHTEY TENFKDRVTM TRDTSTSTVY MELSSLRSED TAVYYCARYF FGSSPNWYFD VWGQGTLVTV SSASTKGPSV FPLAPCSRST SESTAALGCL VKDYFPEPVT VSWNSGALTS GVHTFPAVLQ SSGLYSLSSV VTVPSSNFGT QTYTCNVDHK PSNTKVDKTV ERKCCVECPP CPAPPVAGPS VFLFPPKPKD TLMISRTPEV TCVVVDVSQE DPEVQFNWYV DGVEVHNAKT KPREEQFNST YRVVSVLTVL HQDWLNGKEY KCKVSNKGLP SSIEKTISKA KGQPREPQVY TLPPSQEEMT KNQVSLTCLV KGFYPSDIAV EWESNGQPEN NYKTTPPVLD SDGSFFLYSR LTVDKSRWQE GNVFSCSVMH EALHNHYTQK SLSLSLGK SEQ ID NO:21 SYAIS SEQ ID NO:22 GIGPFFGTANYAQKFQG SEQ ID NO:23 DTPYFDY SEQ ID NO:24 SGDSIPNYYVY SEQ ID NO:25 DDSNRPS SEQ ID NO:26 QSFDSSLNAEV SEQ ID NO:27 QVQLVQSGAE VKKPGSSVKV SCKASGGTFS SYAISVWRQA PGQGLEWMGG IGPFFGTANY AQKFQGRVTI TADESTSTAY MELSSLRSED TAVYYCARDT PYFDYWGQGT LVTVSS SEQ ID NO:28 DIELTQPPSV SVAPGQTARI SCSGDSIPNY YVYWYQQKPG QAPVLVIYDD SNRPSGIPER FSGSNSGNTA TLTISGTQAE DEADYYCQSF DSSLNAEVFG GGTKLTVL SEQ ID NO:29 NYIS SEQ ID NO:30 IIDPDDSYTEYSPSFQG SEQ ID NO:31 YEYGGFDI SEQ ID NO:32 SGDNIGNSYVH SEQ ID NO:33 KDNDRPS SEQ ID NO:34 GTYDIESYV SEQ ID NO:35 EVQLVQSGAE VKKPGESLKI SCKGSGYSFT NYISWVRQMP GKGLEWMGII DPDDSYTEYS PSFQGQVTIS ADKSISTAYL QWSSLKASDT AMYYCARYEY GGFDIWGQGT LVTVSS SEQ ID NO:36 SYELTQPPSV SVAPGQTARI SCSGDNIGNS YVHWYQQKPG QAPVLVIYKD NDRPSGIPER FSGSNSGNTA TLTISGTQAE DEADYYCGTY DIESYVFGGG TKLTVL SEQ ID NO:37 SSYYVA SEQ ID NO:38 AIYTGSGATYKASWAKG SEQ ID NO:39 DGGYDYPTHAMHY SEQ ID NO:40 QASQNIGSSLA SEQ ID NO:41 GASKTHS SEQ ID NO:42 QSTKVGSSYGNH SEQ ID NO:43 QVQLVESGGG LVQPGGSLRL SCAASGFTSH SSYYVAWVRQ APGKGLEWVG AIYTGSGATY KASWAKGRFT ISKDTSKNQV VLTMTNMDPV DTATYYCASD GGYDYPTHAM HYWGQGTLVT VSS SEQ ID NO:44 DVVMTQSPSS LSASVGDRVT ITCQASQNIG SSLAWYQQKP GQAPRLLIYG ASKTHSGVPS RFSGSGSGTD FTLTISSLQP EDVATYYCQS TKVGSSYGNH FGGGTKVEIK SEQ ID NO:45 QVQLVESGGG LVQPGRSLRL SCAASGFTVH SSYYMAWVRQ APGKGLEWVG AIFTGSGAEY KAEWAKGRVT ISKDTSKNQV VLTMTNMDPV DTATYYCASD AGYDYPTHAM HYWGQGTLVT VSSASTKGPS VFPLAPSSKS TSGGTAALGC LVKDYFPEPV TVSWNSGALT SGVHTFPAVL Q SSGLYSLSS VVTVPSSSLG TQTYICNVNH KPSNTKVDKK VEPKSCDKTH TCPPCPAPEL RRGPKVFLFP PKPKDTLMIS RTPEVTCVVV DVSHEDPEVK FNWYVDGVEV HNAKTKPREE QYNSTYRVVS VLTVLHQDWL NGKEYKCKVS NKGLPSSIEK TISKAKGQPR EPQVYTLPPS REEMTKNQVS LTCLVKGFYP SDIAVEWESN GQPENNYKTT PPVLDSDGSF FLYSKLTVDK SRWQQGNVFS CSVLHEALHA HYTRKELSLS P SEQ ID NO:46 DIQMTQSPSS LSASVGDRVT ITCRASQGIS SSLAWYQQKP GKAPKLLIYG ASETESGVPS RFSGSGSGTD FTLTISSLQP EDFATYYCQN TKVGSSYGNT FGGGTKVEIK RTVAAPSVFI FPPSDEQLKS GTASVVCLLN NFYPREAKVQ WKVDNALQSG NSQESVTEQD SKDSTYSL SS TLTLSKADYE KHKVYACEVT HQGLSSPVTK SFNRGEC SEQ ID NO:47 QVQLQESGPGLVKPSETLSLTCTVSGDSVSSSYWTWIRQPPGKGLEWIGYIYYSGSSN YNPSLKSRATISVDTSKNQFSLKLSSVTAADTAVYYCAREGNVDTTMIFDYWGQGTLV TVSS SEQ ID NO:48 AIQMTQSPSSSLSASVGDRVTITCRASQGIRNDLGWYQQKPGKAPKLLIYAASSLQSGVP SRFAGRGSGTDFTLTISSLQPEDFATYYCLQDFNYPWTFGQGTKVEIK SEQ ID NO:49 QVQLQESGPGLVKPSETLSLTCTVSGDSVSSSYWTWIRQPPGKGLEWIGYIYYSGSSNY NPSLKSRATISVDTSKNQFSLKLSSVTAADTAVYYCAREGNVDTTMIFDYWGQGTLVTV SSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVL QSSGLYSLSSVVTVPSSSLGTK TYTCNVDHKPSNTKVDKRVESKYGPPCPPCPAPEFLG GPSVFLFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQ FNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPS QEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSRLTVD KSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK SEQ ID NO:50 AIQMTQSPSSSLSASVGDRVTITCRASQGIRNDLGWYQQKPGKAPKLLIYAASSLQSGVP SRFAGRGSGTDFTLTISSLQPEDFATYYCLQDFNYPWTFGQGTKVEIKRTVAAPSVFIF PPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSS TLTLSKADYEKHKVY ACEVTHQGLSSPVTKSFNRGEC

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[ Figure 1 ] is a schematic diagram of the clinical trial plan.

[ Figure 2A- 2G ] illustrates the timeline of activities for the clinical trial protocol described in Example 1. The following abbreviations were used in the activity schedule: ADA = antidrug antibodies; AE = adverse event; AKI = acute renal injury; CPB = cardiopulmonary bypass; CT = computed tomography; D and d = days; ECG = electrocardiogram; ED = premature discontinuation; eGFR = estimated glomerular filtration rate; EQ 5D 5L = European Quality of Life Group 5 dimensions 5 levels; FACIT-fatigue = Functional Assessment of Chronic Illness Therapy-fatigue; FSH = follicle-stimulating hormone; ICU = intensive care unit; KDQOL 36 = Kidney Disease Quality of Life Tool-36 items; KRT = renal replacement therapy; PD = pharmacodynamics; PK = pharmacokinetics; pRBC = packed red blood cells; sCysC = serum cystin C; RBC = red blood cells; STS =American College of Thoracic Surgeons; WOCBP =women of childbearing potential.

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TW202423479A_112136458_SEQL.xml

Claims (50)

A method for preparing a human patient with chronic kidney disease (CKD) for cardiopulmonary bypass (CPB) cardiac surgery, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before the surgery in the following dose: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d) For patients weighing ≥ 100 kg, 3600 mg. A method for inhibiting terminal complement activation in a human patient with CKD before CPB cardiac surgery, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before the surgery in the following dose: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)  For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or d)  For patients with a body weight of ≥ For a 100 kg patient, 3600 mg. A method for treating a human patient with CKD before CPB cardiac surgery, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before the surgery in the following dose: a)   2700 mg for patients with a body weight of ≥ 30 to < 40 kg; b)  3000 mg for patients with a body weight of ≥ 40 to < 60 kg; c)   3300 mg for patients with a body weight of ≥ 60 to < 100 kg; or d)  3300 mg for patients with a body weight of ≥ 100 kg patients, 3600 mg. A method for preventing or reducing cardiac surgery-associated acute renal injury (CSA-AKI) in a human patient with CKD, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before CPB cardiac surgery in the following doses: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)  For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 3300 mg for patients weighing 60 to < 100 kg; or d) 3600 mg for patients weighing ≥ 100 kg. A method for preventing or reducing one or more major adverse renal events (MAKE) in a human patient with CKD, wherein the method comprises administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the anti-C5 antibody or an antigen-binding fragment thereof comprises CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, and wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before CPB cardiac surgery in the following doses: a)   For patients with a body weight of ≥ 30 to < 40 kg, 2700 mg; b)  For patients with a body weight of ≥ 40 to < 60 kg, 3000 mg; c)   For patients with a body weight of ≥ 60 to < 100 kg, 3300 mg; or d)  For patients weighing ≥ 100 kg, 3600 mg. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered at least one calendar day prior to the CPB. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered one to seven calendar days before the CPB. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof further comprises a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc constant region comprises Met429Leu and Asn435Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each using EU numbering. The method of any of the preceding claims, wherein the anti-C5 antibody comprises a heavy chain variable region as shown in SEQ ID NO:12 and a light chain variable region as shown in SEQ ID NO:8. The method of any of the preceding claims, wherein the anti-C5 antibody further comprises a heavy chain constant region as shown in SEQ ID NO:13. The method of any of the preceding claims, wherein the antibody comprises a heavy chain polypeptide comprising the amino acid sequence shown in SEQ ID NO:14 and a light chain polypeptide comprising the amino acid sequence shown in SEQ ID NO:11. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof binds to human C5 with a K _D in the range of 0.1 nM ≤ affinity dissociation constant (K _D ) ≤ 1 nM (e.g., about 0.5 nM) at pH 7.4 and 25°C. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof binds to human C5 with a _KD of ≥ 10 nM (e.g., about 22 nM) at pH 6.0 and 25°C. The method of any one of claims 1-13, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 30 to < 40 kg at a dose of 2700 mg. The method of any one of claims 1-13, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg at a dose of 3000 mg. The method of any one of claims 1-13, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg at a dose of 3300 mg. The method of any one of claims 1-13, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg at a dose of 3600 mg. The method of any preceding claim, wherein the treatment maintains the serum trough concentration of the anti-C5 antibody at 175 μg/mL or greater. The method of any preceding claim, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody at 200 μg/mL or greater. The method of any of the preceding claims, wherein the anti-C5 antibody or antigen-binding fragment thereof is formulated for intravenous administration. The method of any of the preceding claims, wherein the cardiac surgery is selected from the group consisting of coronary artery bypass grafting (CABG), valve replacement or repair, insertion of a pacemaker or implantable cardioverter defibrillator (ICD), maze surgery, maze surgery, heart transplantation, and insertion of a ventricular assist device (VAD) or total artificial heart (TAH), and transcatheter structural heart surgery. The method of any of the preceding claims, wherein a single preoperative weight-based dose of the anti-C5 antibody or antigen-binding fragment thereof results in complete C5 inhibition for at least 18 days. The method of any preceding claim, wherein the method prevents the need for renal replacement therapy (KRT). The method of any of the preceding claims, wherein the method prevents or reduces CSA-AKI in a human patient with CKD. A method as described in any of the preceding claims, wherein the human patient comprises a patient with cardiac surgery-associated acute renal injury (CSA-AKI), wherein CSA-AKI is characterized by: a)   an increase in serum creatinine (sCr) or serum cystin C (sCysC) of ≥ 0.3 mg/dL over a 48-hour period within 7 days after CPB and/or b)  an increase in sCr or sCysC of ≥ 1.5 times baseline within 7 days after CPB or at 15, 30, 60, or 90 days after CPB. The method of any of the preceding claims, wherein the human patient does not have severe CSA-AKI as assessed by modified Kidney Disease Improving Global Outcomes (KDIGO) criteria based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB. The method of any of the preceding claims, wherein the human patient does not have severe CSA-AKI as assessed by the modified Risk, Injury, Failure, Renal Function Loss, and End-Stage Kidney Disease (RIFLE) criteria based on the highest sCr observed within 7, 30, 45, 60, or 90 days after CPB. The method of any of claims 1-27, wherein the method results in stable CSA-AKI characterized by sCr ≥2.0 - < 3.0 times baseline within 7, 30, 45, 60, or 90 days post-operatively. The method of any of claims 1-28, wherein the method results in improvement in CSA-AKI within 7, 30, 45, 60, or 90 days post-operatively, wherein the improvement is characterized by sCr ≥1.5 - < 2.0 times baseline. The method of any of claims 1-28, wherein the method results in partial recovery of CSA-AKI within 7, 30, 45, 60, or 90 days post-operatively, wherein the partial recovery is characterized by sCr ≥ 1.1 - < 1.5 times baseline. The method of any one of claims 1-28, wherein the method results in complete recovery of CSA-AKI within 7, 30, 45, 60 or 90 days post-operatively, wherein the complete recovery is characterized by sCr < 1.1 times baseline. The method of any of the preceding claims, wherein the method prevents or reduces one or more MAKEs in a human patient suffering from CKD. The method of any of claims 5-32, wherein the one or more MAKEs are selected from the group consisting of: a)   Persistent renal dysfunction (SKD), defined as estimated glomerular filtration rate (eGFR) > 25% below baseline after CPB, b)   Development of renal replacement therapy (KRT) after CPB, and c)   Death from any cause after CPB. The method of claim 33, wherein the decrease in eGFR is determined by the Chronic Kidney Disease Epidemiology Institute (CKD-EPI) formula based on serum cysteine C (sCysC) or serum creatinine (sCr). A method as claimed in any preceding claim, wherein the method results in a change from baseline in quality of life as assessed by a quality of life assessment. The method of claim 35, wherein the quality of life assessment is the Kidney Disease Quality of Life Instrument (KDQOL-36), the European Quality of Life Group 5 Dimensions 5 Levels (EQ-5D-5L), or the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Scale. The method of any of the preceding claims, wherein the method results in a shift toward normal levels of biomarkers associated with vascular inflammation (e.g., abscess tumor necrosis factor receptor 1 [TNF-R1 or sTNF-R1]), biomarkers associated with endothelial damage and/or activation (e.g., thrombomodulin), biomarkers associated with renal damage (e.g., neutrophil gelatin-associated lipocalin [NGAL]), biomarkers associated with cell cycle arrest inducers (e.g., tissue inhibitor of metalloproteinase-2 [TIMP-2]), and/or complement proteins and complement activation pathway products (e.g., soluble C5b-9). A kit comprising: (a) a dose of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or the antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively; and (b) instructions for using the anti-C5 antibody or the antigen-binding fragment thereof in the method as described in any of the preceding claims. An anti-C5 antibody or antigen-binding fragment thereof for use in preparation for cardiopulmonary bypass (CPB) cardiac surgery in a human patient with CKD, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. An anti-C5 antibody or an antigen-binding fragment thereof for inhibiting terminal complement activation in a human patient with CKD prior to CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. An anti-C5 antibody or an antigen-binding fragment thereof for treating a human patient with chronic kidney disease prior to CPB cardiac surgery, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once prior to the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. An anti-C5 antibody or an antigen-binding fragment thereof for preventing or reducing CSA-AKI in a human patient with chronic kidney disease, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. An anti-C5 antibody or antigen-binding fragment thereof for preventing or reducing one or more MAKEs in a human patient with chronic renal disease, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. Use of an anti-C5 antibody or an antigen-binding fragment thereof for preparing a human patient with CKD for CPB cardiac surgery, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. Use of an anti-C5 antibody or an antigen-binding fragment thereof for inhibiting terminal complement activation in a human patient with CKD prior to CPB cardiac surgery, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once prior to the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. Use of an anti-C5 antibody or an antigen-binding fragment thereof for treating a human patient with chronic kidney disease prior to CPB cardiac surgery, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once prior to the surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. Use of an anti-C5 antibody or an antigen-binding fragment thereof in preventing or reducing CSA-AKI in a human patient with chronic renal disease, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. Use of an anti-C5 antibody or an antigen-binding fragment thereof in preventing or reducing one or more MAKEs in a human patient suffering from chronic renal disease, wherein the anti-C5 antibody or an antigen-binding fragment thereof is administered once before surgery at the following doses: a)   2700 mg for patients weighing ≥ 30 to < 40 kg; b)  3000 mg for patients weighing ≥ 40 to < 60 kg; c)   3300 mg for patients weighing ≥ 60 to < 100 kg; or d)  3600 mg for patients weighing ≥ 100 kg. The anti-C5 antibody or antigen-binding fragment thereof as described in any one of claims 39-44, wherein the anti-C5 antibody or antigen-binding fragment thereof is ravulizumab (ULTOMIRIS®). The use as described in any of claims 45-49, wherein the anti-C5 antibody or antigen-binding fragment thereof is ravulizumab (ULTOMIRIS®).

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