A multicenter randomized controlled trial to evaluate the efficacy and safety of nelfinavir in patients with mild COVID-19

Nelfinavir, an orally administered inhibitor of human immunodeficiency virus protease, inhibits the replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro. We conducted a randomized controlled trial to evaluate the clinical efficacy and safety of nelfinavir in patients with SARS-CoV-2 infection. We included unvaccinated asymptomatic or mildly symptomatic adult patients who tested positive for SARS-CoV-2 infection within 3 days before enrollment. The patients were randomly assigned (1:1) to receive oral nelfinavir (750 mg; thrice daily for 14 days) combined with standard-of-care or standard-of-care alone. The primary endpoint was the time to viral clearance, confirmed using quantitative reverse-transcription PCR by assessors blinded to the assigned treatment. A total of 123 patients (63 in the nelfinavir group and 60 in the control group) were included. The median time to viral clearance was 8.0 (95% confidence interval [CI], 7.0 to 12.0) days in the nelfinavir group and 8.0 (95% CI, 7.0 to 10.0) days in the control group, with no significant difference between the treatment groups (hazard ratio, 0.815; 95% CI, 0.563 to 1.182; P = 0.1870). Adverse events were reported in 47 (74.6%) and 20 (33.3%) patients in the nelfinavir and control groups, respectively. The most common adverse event in the nelfinavir group was diarrhea (49.2%). Nelfinavir did not reduce the time to viral clearance in this setting. Our findings indicate that nelfinavir should not be recommended in asymptomatic or mildly symptomatic patients infected with SARS-CoV-2. The study is registered with the Japan Registry of Clinical Trials (jRCT2071200023). IMPORTANCE The anti-HIV drug nelfinavir suppresses the replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro. However, its efficacy in patients with COVID-19 has not been studied. We conducted a multicenter, randomized controlled trial to evaluate the efficacy and safety of orally administered nelfinavir in patients with asymptomatic or mildly symptomatic COVID-19. Compared to standard-of-care alone, nelfinavir (750 mg, thrice daily) did not reduce the time to viral clearance, viral load, or the time to resolution of symptoms. More patients had adverse events in the nelfinavir group than in the control group (74.6% [47/63 patients] versus 33.3% [20/60 patients]). Our clinical study provides evidence that nelfinavir, despite its antiviral effects on SARS-CoV-2 in vitro, should not be recommended for the treatment of patients with COVID-19 having no or mild symptoms

Diffuse Glomerular Nodular Lesions in Diabetic Pigs Carrying a Dominant-Negative Mutant Hepatocyte Nuclear Factor 1-Alpha, an Inheritant Diabetic Gene in Humans

<div><p>Glomerular nodular lesions, known as Kimmelstiel-Wilson nodules, are a pathological hallmark of progressive human diabetic nephropathy. We have induced severe diabetes in pigs carrying a dominant-negative mutant hepatocyte nuclear factor 1-alpha (HNF1α) P291fsinsC, a maturity-onset diabetes of the young type-3 (MODY3) gene in humans. In this model, glomerular pathology revealed that formation of diffuse glomerular nodules commenced as young as 1 month of age and increased in size and incidence until the age of 10 months, the end of the study period. Immunohistochemistry showed that the nodules consisted of various collagen types (I, III, IV, V and VI) with advanced glycation end-product (AGE) and <i>N</i>^ε-carboxymethyl-lysine (CML) deposition, similar to those in human diabetic nodules, except for collagen type I. Transforming growth factor-beta (TGF-β) was also expressed exclusively in the nodules. The ultrastructure of the nodules comprised predominant interstitial-type collagen deposition arising from the mesangial matrices. Curiously, these nodules were found predominantly in the deep cortex. However, diabetic pigs failed to show any of the features characteristic of human diabetic nephropathy; e.g., proteinuria, glomerular basement membrane thickening, exudative lesions, mesangiolysis, tubular atrophy, interstitial fibrosis, and vascular hyalinosis. The pigs showed only Armanni-Ebstein lesions, a characteristic tubular manifestation in human diabetes. RT-PCR analysis showed that glomeruli in wild-type pigs did not express endogenous HNF1α and HNF1β, indicating that mutant HNF1α did not directly contribute to glomerular nodular formation in diabetic pigs. In conclusion, pigs harboring the dominant-negative mutant human MODY3 gene showed reproducible and distinct glomerular nodules, possibly due to AGE- and CML-based collagen accumulation. Although the pathology differed in several respects from that of human glomerular nodular lesions, the somewhat acute and constitutive formation of nodules in this mammalian model might provide information facilitating identification of the principal mechanism underlying diabetic nodular sclerosis.</p></div

Reverse transcription-PCR for endogenous HNF1α and HNF1β in wild-type pigs at 4 weeks of age.

<p>Both HNF1α (<b>A</b>) and HNF1β (<b>B</b>) were negative in isolated glomeruli. Liver was used as a positive control, and heart as a negative control. G  =  isolated glomeruli; L  =  liver; H  =  heart.</p

Transmission electron microscopy at age 4 weeks (A,B,E) and 5 months (C,D) in transgenic pigs.

<p><b>A</b>) In 4-week-old transgenic pigs, mesangial widening is associated with fiber deposition in the mesangial matrices. Magnification: 2,000×. <b>B</b>) Fibers accumulated at mesangial areas, forming early lesion. Magnification: 500×. <b>C</b>) At 5 months, established glomerular nodules showed that mesangial areas and capillary lumens are filled with bright fibers (arrows). Vacuolations of proximal tubules were also seen (arrowheads). Magnification: 300×. <b>D</b>) Subendothelial widening with loss of endothelial fenestration and mesangial interposition are shown. Note that collagen is also found in the subendothelial spaces (arrows). Magnification: 1,500×. <b>E</b>) The nodules consist of fibril collagens with cross striation, indicating interstitial-type forms of collagen fibrils. Magnification: 10,000×. <b>F</b>) Thickness of glomerular basement membranes in transgenic pigs was no different from those in wild-type pigs at 4 weeks and 5 months old. Transgenic pigs; n = 1, wild-type pigs; n = 3. Tg  =  transgenic pigs; WT  =  wild-type pigs; GBM  =  glomerular basement membrane.</p

Renal pathological findings at age 4 and 19 weeks in transgenic pigs.

<p><b>A</b>) In transgenic pigs, mesangial expansion commenced as early as 4 weeks. At 19 weeks, distinct glomerular nodules had formed. Magnification: 400×. <b>B</b>) The number of glomeruli with nodules as a fraction of the total number was compared between the superficial cortex and deep cortex. <b>C</b>) Glomerular tuft area in superficial and deep cortexes was compared between wild-type pigs and transgenic pigs. Transgenic pigs; n = 3, wild-type pigs; n = 3. *<i>P</i><0.05. WT  =  wild-type pigs; Tg  =  transgenic pigs.</p

Analysis of biochemical parameters in transgenic (Tg) and wild-type (WT) pigs at age 1, 5 and 10 months.

<p>Aberrations: Tg  =  transgenic pigs; WT  =  wild-type pigs; *: n = 1.</p