WO2014118705A1

WO2014118705A1 - Methods of treating chronic kidney disease-mineral and bone disorder using sclerostin antagonists

Info

Publication number: WO2014118705A1
Application number: PCT/IB2014/058619
Authority: WO
Inventors: Michaela Kneissel; Uwe Junker; Ronenn Roubenoff
Original assignee: Novartis Ag
Priority date: 2013-01-31
Filing date: 2014-01-28
Publication date: 2014-08-07

Abstract

The disclosure relates to method for treating Chronic kidney disease (CKD) with evidence of Mineral and Bone Disorder (MBD), including patients having a diagnosis of CKD-MBD, e.g., stage 3-5 CKD patients (e.g., CKD-5D patients) having renal osteodystrophy (ROD), preferably adynamic bone disease (ABD), by antagonizing Sclerostin expression, secretion, signaling and/or function, e.g, using an anti-sclerostin antibody or antigen binding fragment therof (e.g., Antibody 1).

Description

METHODS OF TREATING CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER USING SCLEROSTIN ANTAGONISTS

RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent Application No.

61/758,966, filed January 31, 2013, the contents of which are incorporatd by reference herein in their entirety.

TECHNICAL FIELD

The disclosure relates to method for treating Chronic kidney disease (CKD) with evidence of Mineral and Bone Disorder (MBD), including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, by antagonizing Sclerostin expression, secretion, signaling and/or function.

BACKGROUND OF THE DISCLOSURE

Chronic kidney disease (CKD) refers to heterogeneous disorders affecting the structure and function of the kidney. The definition of CKD, and the management thereof, is based on the presence of kidney damage (i.e., albuminuria) or decreased kidney function (i.e., glomerular filtration rate (GFR) <60 mL/min per 1 · 73 m²) for 3 months or more, irrespective of clinical diagnosis. CKD is classified into five stages on the basis of GFR, with stage five being a GFR of less than 15 mL/min per 1.73 m² or dialysis (see, e.g., Levey et al. (2003) Ann. Intern. Med. 139: 137-147). Patients with stage 5 CKD (CKD-5) are treated with kidney replacement, i.e., dialysis (CKD-5D) or transplant (CKD-5T).

Alteration in bone morphology can begin early in the course of progressive CKD and results in bone remodeling, loss of bone mass, and increased risk of fracture in many patients with late stage (i.e., stage 3-5) CKD. Bone abnormalities are found almost universally in patients with CKD requiring dialysis (stage 5D), and in the majority of patients with CKD stages 3-5. Disturbances in bone and mineral metabolism in patients with CKD have been classified as their own clinical entity known as CKD-Mineral and Bone Disorder (CKD- MBD), and are characterized by abnormalities in serum calcium, phosphorus, 1,25- dihydroxycholecalciferol, FGF-23 and PTH (see, e.g., Moe et al. (2006) Kidney International 69: 1945-53). CKD-MBD is a systemic disorder manifested by either one or a combination of: 1) abnormalities of calcium, phosphorus, PTH or vitamin D metabolism; 2) abnormalities in bone turnover, mineralization, volume, linear growth or strength; and 3) vascular or other soft tissue calcification (Moe et al. (2006)). Renal osteodystrophy (ROD) refers the bone histopathology in patients with CKD-MBD, which is routinely classified into four major subtypes: high-turnover ROD (osteitis fibrosa) (which includes mild hyperparathyroid (HPT)- related bones disease), mixed uremic osteodystrophy, osteomalacia and adynamic bone disease (ABD) (Malluche and Faugere (1990) Kidney Int 38: 193-211; Moe et al. (2006)). ROD is found almost universally in patients with CKD-5, and in the majority of patients with CKD stages 3-5. (Moe et al. KDIGO guideline: Diagnosis of CKD-MBD: biochemical abnormalities Kidney International (2009) 76 (Suppl 113), S22-S49).

Fracture rates in patients with CKD are high and increase with declining kidney function. Fracture prevalence varies widely in patients with CKD-5D, ranging from 10 to 50%. Hip fracture prevalence ranges from 2 to 8%, and vertebral fractures from 7 to 33%. Not only is the fracture rate higher among patients with CKD-5D, but outcomes are worse compared with the general population. For example, a recent retrospective study reported that dialysis patients have a 1-year mortality rate of 64% following a hip fracture compared with 15-20% in the general population; furthermore, their hip fractures occur at a younger age than in the general population (16 and 13 years younger among men and women, respectively). (Coco et al. (2006) Am J Kidney Dis 36(6): 1115-1121). Around 20% of CKD-5D patients develop ABD, which features low bone turnover and high fracture risk. (Spasovski et al. (2003) Nephrol. Dial. Transplant. 18: 1159-1166).

There is little information on the prevention or treatment of fractures in the CKD- MBD population, as abnormal kidney function is an exclusion criterion for nearly all clinical trials that study the general osteoporosis population. Moreover, the pathogenesis of bone disease in patients with CKD-MBD is different from that in postmenopausal osteoporosis, e.g, bisphosphonates can induce ABD. (Moe et al. 2009). This lack of treatment data has resulted in the development of international clinical practice guidelines for treating CKD-MBD, i.e., the Kidney Disease Improving Global Outcomes (KDIGO) (Moe et al. (2009)). These guidelines recommend standard osteoporosis management (i.e., bisphosphonate, teriparatide, raloxifene) in patients with CKD stages 1-3 who have normal PTH levels. For the treatment of bone in patients with CKD stages 3 with biochemical abnormalities of CKD-MBD and low BMD (or fragility fractures), these guidelines indicate that bisphosphonate treatment may be considered with consideration of a bone biopsy. However, for the treatment of bone in patients with CKD stages 4-5 with biochemical abnormalities of CKD-MBD and low BMD (or fragility fractures), the KDIGO guidelines do not recommend the routine use of bisphosphonate, teriparatide or raloxifine, especially in light of safety concerns that arise due to the inherent multi -faceted nature of MBD.

Cejka et al. (2010) report on seven hemodialysis patients with ABD having a median iPTH level of 22 pg/ml who received teriparatide, an osteoanabolic agent, branded for treatment of severe postmenopausal osteoporosis, in an open-label, prospective, 6-month observational pilot-study. (Cejka et al. (2010) Blood Press. Res. 33:221-26). Teriparatide (PTH) therapy led to a significant increase in lumbar spine, but not femoral neck bone mineral density. Thus, PTH could present one option to treat at least some types of ROD, e.g., ABD (Cejka and Haas (2011) Seminars in Dialysis 24:431-33). However, teriparatide carries an increased risk of osteosarcoma, it can lead to abnormal blood calcium and phosphorus in CKD patients, and preexisting hyperparathyroidism could be exacerbated by teriparatide (Cejka and Haas (2011); Moe et al. (2009)). Furthermore, ABD is particularly difficult to treat, as most of the current anti-resorptive drugs (such as bisphosphonate and raloxifene) or anabolic drugs (such as teriparatide) are contraindicated, and other drugs (e.g., calcitonin) have no efficacy against hip fracture, which is highly increased in ABD patients. Given the lack of treatment options and the potential safety concerns for patients with CKD-MBD, particularly CKD-5 patients, there is a need to develop new agents to effectively address the bone component of CKD-MBD.

SUMMARY OF THE DISCLOSURE

Sclerostin is a potent negative regulator of bone formation. Increasing evidence suggests that sclerostin exerts its action in adult bone by antagonizing Wnt signaling by binding to Wnt co-receptors, thus preventing signaling activation by Wnt ligands. In adult bone, sclerostin is expressed in osteocytes, which are derived from osteoblasts residing within the mineralized bone matrix. The SO ST gene is a direct target gene of parathyroid hormone (PTH) and SOST expression is suppressed in adult bone following intermittent administration of a bone anabolic dose of PTH(l-34) (Keller and Kneissel (2005) Bone 37(2): 148-58.), suggesting that part of the bone anabolic effect of PTH might be mediated via SOST repression. In a cross-sectional bone biopsy study in sixty long-term hemodialysis patients with CKD-5D, Cejka et al. (2011a) show that serum sclerostin is higher in patients with CKD-5D than in healthy control patients, and that high serum sclerostin associates with decreased bone turnover and osteoblast number, indicating low bone growth (Cejka et al. (2011a) Clin J Am Soc Nephrol 6:877-882). The authors conclude that serum sclerostin measurement may be a valuable predictor of bone turnover rate in stage 5 CKD patients, while noting that the increased retention of sclerostin in CKD patients (in comparison to healthy control patients) could be due to lack of renal function and/or increased sclerostin production associated with ROD (Cejka et al. (2011a); see also Drueke and Lafag-Proust (2011) Clin J Am Soc Nephrol 6:700-703). However, Cejka et al. (2011b) published a separate report of the unexpected positive correlation of serum sclerostin with increased bone mineral density (BMD) and improved bone microacrchitecture in hemodialysis patients, which contradicts current knowledge of sclerostin function as a negative regulator of bone growth (Cejka et al. (2011b) Nephrol. Dial. Transplant. 0: 1-5). Thus, the actual role of sclerostin in CKD-MBD remains unclear.

Antibody 1 is a fully human high affinity, neutralizing, anti-sclerostin mAb (IgGilambda) which has displayed potent in vitro activity, and bone anabolic efficacy in a number of rodent models of osteoporosis (See, e.g., WO09047356, which is hereby incorporated by reference herein in its entirety). Disclosed herein are the results from study A2101, in which Antibody 1 was well-tolerated and showed significant increases in bone formation biomarkers and BMD after single ascending doses in healthy postmenopausal osteopenic women. Disclosed herein is also study A2204, which is designed to evaluate safety and tolerability and bone anabolic response using ¹⁸F-fluroide PET imaging after a single administration of Antibody 1 in patients with CKD-5D on hemodialysis and with evidence of MBD.

Accordingly, provided herein are, inter alia, methods of treating CKD with evidence of MBD in a patient (e.g., a human) in need thereof, comprising administering to said patient a therapeutically effective amount of at least one anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1. Also disclosed herein are anti-sclerostin antibodies or antigen-binding fragments thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, for use in treating CKD with evidence of MBD in a patient in need thereof. Further disclosed herein are uses of anti-sclerostin antibodies or antigen-binding fragments thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, for the manufacture of a medicament for treating CKD with evidence of MBD, in a patient in need thereof.

In CKD, there is generally high PTH and high Fibroblast Growth Factor 23 (FGF23) coupled with PTH resistance (see, e.g., Lavi-Moshayoff et al. (2010 Am J Physiol Renal Physiol 299:F882-F889; Silver et al. (2012) Nephrol Dial Transplant 27: 1715-20). However, in ABD, there is often decreased PTH (Cejka and Haas (2011) Seminars in Dialysis 24:431- 33; Cejka (2010) Kidney Blood Pres Res 33:221-26). We therefore believe that ABD patients may benefit from a PTH increase if they are not PTH resistant. Accordingly, disclosed herein are also methods of increasing serum PTH levels in a patient in need thereof (e.g., an ABD patient that is not resistant to PTH), comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient.

It is also known that high serum phosphate leads to vascular calcification, which is common in CKD and associated with increased morbidity and mortality (Moe and Chen (2007) JASN 19:213-216). Accordingly, disclosed herein are methods of reducing serum phosphate levels in a patient in need thereof (e.g., a CKD patient), comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient.

Finally, high levels of FGF23 can cause imbalance in calcium and phosphate and homeostasis, leading to increased phosphate secretion from kidney and decreased and calcium absorption by the kidney (see, e.g., Shimada et al. (2004) J Bone Miner Res 19:429-35; Yamashita et al. (2004) Eur J. Endocrinol 151 :55-60; White et al (2000) Nat Genet 26:345- 48). High levels of FGF23 are implicated in left ventricular hypertrophy and are associated with increased mortality in long-term hemodialysis patients. (Jean et al. (2009) Nephrol Dial Transplant 24:2792-96; Faul et al. (2011) J Clin Invest. 121 4393:4408). Accordingly, disclosed herein are methods of reducing FGF23 levels in a patient in need thereof (e.g., a CKD patient), comprising administering a therapeutically effective amount of an anti- sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient.

Further embodiments of the disclosed methods, uses, kits and compositions may be found in the Detailed Description of the Disclosure and the Claims.

BRIEF DESCRIPTION OF THE FIGURES Figure 1 : in osteopenic female volunteers, Antibody 1 shows a clear increase in lumbar spine bone mineral density (BMD) at 20 mg/kg at day 85 (d85) and the end of study (EOS) versus baseline.

Figure 2: Fg/23 expression is decreased in Sost deficient mice. A: Fg/23 expression strongly and significantly decreased by 63% relative to wild-type in 6-month-old Sost deficient female mice (n = 10 Sost KO [Sosf ^{~ ~}] versus n = 10 wild-type littermate [Sost^/+], p < 0.01). B. Fgf23 serum levels are significantly reduced by 24% in 6-month-old Sost KO female mice (n = 6 Sost KO [.Sosf -] versus n = 6 wild-type littermate [Sost^/+], p < 0.05).

DETAILED DESCRIPTION OF THE DISCLOSURE

Therapeutic Methods and Uses

The disclosure provides methods of treating patients having Chronic kidney disease (CKD) with evidence of Mineral and Bone Disorder (MBD), including patients having a diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, by inhibiting sclerostin expression, signalling, secretion and/or function using at least one scerlostin antagonist, preferably at least one anti-sclerostin antibody or antigen- binding fragment thereof.

Disclosed herein are methods of treating chronic kidney disease (CKD) with evidence of mineral and bone disorder (MBD), comprising administering to a patient having CKD with evidence of MBD a therapeutically effective amount of an anti-sclerostin antibody or antigen- binding fragment thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5. Disclosed herein are also methods of reducing serum phosphate levels in a patient in need thereof, comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, to said patient, e.g, a patient having vascular calcification. Disclosed herein are also methods of increasing serum PTH levels in a patient in need thereof, comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, to said patient, e.g, a patient having Adynamic Bone Disease (ABD). Disclosed herein are also methods reducing FGF23 levels in a patient in need thereof, comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen- binding fragment thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, to said patient, e.g, a patient having left ventricular hypertrophy.

Further disclosed herein are anti-sclerostin antibodies or antigen-binding fragments thereof, e.g., Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for use in treating CKD with evidence of MBD in a patient in need thereof. Disclosed herein are also anti-sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for use in reducing serum phosphate levels in a patient in need thereof, e.g, a patient having vascular calcification. Disclosed herein are also anti- sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for use in increasing serum PTH levels in a patient in need thereof, e.g, a patient having ABD. Disclosed herein are also anti-sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for use in reducing FGF23 levels in a patient in need thereof, e.g, a patient having left ventricular hypertrophy.

Further disclosed herein are uses of anti-sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for the manufacture of a medicament for treating CKD with evidence of MBD in a patient in need thereof. Disclosed herein are also uses of anti-sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for the manufacture of a medicament for reducing serum phosphate levels in a patient in need thereof, e.g, a patient having vascular calcification. Disclosed herein are also uses of anti- sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for the manufacture of a medicament for increasing serum PTH levels in a patient in need thereof, e.g, a patient having ABD. Disclosed herein are also uses of anti-sclerostin antibodies or antigen-binding fragments thereof, e.g, Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5, for the manufacture of a medicament for reducing FGF23 levels in a patient in need thereof, e.g, a patient having left ventricular hypertrophy.

"Chronic Kidney Disease" (CKD) is defined as either kidney damage or decreased kidney function (decreased glomerular filtration rate (GFR), i.e., GFR <60 mL/min per 1·73 m²) for three months or more. (Levey et al.). CKD is classified into five stages on the basis of

GFR: more than 90 mL/min per 1·73 m² (stage 1), 60-89 mL/min per 1·73 m² (stage 2), 30-

59 mL/min per 1·73 m² (stage 3), 15-29 mL/min per 1·73 m² (stage 4), and less than 15 mL/min per 1·73 m² (stage 5). (Levey et al.). Stage 5 CKD patients that are on dialysis are referred to as having "CKD-5D". In preferred embodiments of the disclosed methods, uses and kits, the patient has stage 3-5 CKD, most preferably stage 5 CKD.

The phrase "Chronic Kidney Disease-Mineral and Bone Disorder" (CKD-MBD) refers to a systemic disorder of mineral and bone metabolism due to CKD, which is manifested by either one or a combination of: 1) abnormalities of calcium, phosphorus, PTH or vitamin D metabolism; 2) abnormalities in bone turnover, mineralization, volume, linear growth or strength; and 3) vascular or other soft tissue calcification. (Moe et al. (2006), Table 3). The phrase "chronic kidney disease (CKD) with evidence of mineral and bone disorder (MBD)" includes patient having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, or having CKD and being suspected of developing MBD in the future. In some embodiments of the disclosed methods, uses and kits, the patient has chronic kidney disease (CKD) with evidence of mineral and bone disorder (MBD). In preferred embodiments of the disclosed methods, uses and kits, the patient has CKD-MBD. In some embodiments, the patient has has serum calcium, PO₄, PTH and vitamin D levels within KDIGO guidelines (Moe et al. 2009) for greater than 80% of serum samples over the past three months.

"Renal osteodystrophy" (ROD) is defined as an alteration of bone morphology in patients with CKD. (Moe et al. (2006)). It is one measure of the skeletal component of the systemic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy. The components used to classify ROD include turnover, mineralization and bone volume (TMV). ROD is routinely classified into four major sub-types: high-turnover ROD (osteitis fibrosa) (which includes mild hyperparathyroid (HPT)-related bones disease), mixed uremic osteodystrophy, osteomalacia and adynamic bone disease (ABD) (Malluche and Faugere (1990); Moe et al.). In preferred embodiments of the disclosed methods, uses and kits, the patient has ROD.

Adynamic bone disease (ABD) is a type of ROD characterized by reduced osteblasts and osteoclasts, no accumulation of osteoid and markedly low bone turnover. (Coen (2005) J.

Nephrol 18: 117-22; Brandenburg and Floege (2008) NDT Plus 3: 135-47). ABD is characterized by a low-bone turnover without osteoid accumulation, i.e. with a thin osteoid seam. The rate of collagen synthesis by osteoblasts and the subsequent mineralization of bone collagen are subnormal in ABD. The latter distinguishes ABD from osteomalacia, where a mineralization defect exceeds the defects in bone formation, resulting in a relative osteoid excess. ABD can be diagnosed by a skilled clinician using, e.g., bone biopsy and histomorphometric analysis, ¹⁸F-fluoride PET-CT imaging, or serum intact PTH (iPTH) levels per country-specific and/or local kidney disease clinical practice guidelines (e.g., <100 pg/ml [11.0 pmol/L] as per KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease (2003) Am J Kidney Disease 42:S 1-S139) (Brandenburg and Floege (2008) NDT Plus 3: 135-47), etc. In patients with CKD stages 3-5D, measurements of bone-specific alkaline phosphatase (bALP) can also be used to evaluate bone disease (such as ABD) because markedly high or low values predict underlying bone turnover (Sardiwal et al. (2012) Kidney Int. 82(1): 100-105. Thus, ABD may be evidenced by elevated bALP. ABD is currently the most common finding in dialysis patients and estimated to be present in approximately 40-50% (Salusky (2001) J. Am Soc Nephrol 12: 1978-85). In preferred embodiments of the disclosed methods, uses and kits, the patient has ABD. In further embodiments, the ABD is evidenced by bone biopsy and histomorphometric analysis, ¹⁸F- fluoride PET-CT imaging, or serum intact PTH (iPTH) levels of less than the iPTH levels considered indicative of ABD for a particular country-specific and/or local kidney disease clinical practice guideline (e.g., less than 100 pg/ml).

Dialysis is a process for removing waste and excess water from the blood, and is used primarily to replace lost kidney function in people with CKD and renal failure. There are three primary types of dialysis (hemodialysis, periotoneal dialysis, and hemofiltration) and two secondary types of dialysis (hemodiafiltration, which combines aspects of hemodialysis and hemofiltration, and intestinal dialysis, which employs dietary supplement, e.g., soluble fiber, polyethylene glycol, mannitol, etc.) to aid in elimination of nitrogen). Hemodialysis can be further distinguished by membrane pore size ("high flux" vs "low flux") and how the dialysis fluid is prepared (on-line, i.e., continuous mixing and immediate use, vs batchwise preparation). In some embodiments of the disclosed methods, uses and kits, the patient is on hemodialysis, peritoneal dialysis, hemofiltration, or hemodiafiltration. In preferred embodiements of the disclosed methods, uses and kits, the patient is on high-flux hemodialysis, on-line hemodialysis or both high -flux and on-line hemodialysis. In some embodiments the patient is on hemodialysis, hemofiltration or hemodiafiltration 3 times per week for at least 3 months.

"Kt/Vurea" is a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy: K - dialyzer clearance of urea; t - dialysis time; V_urea - volume of distribution of urea, approximately equal to patient's total body water. In the context of hemodialysis, Kt/Vurea is a dimensionless number. In peritoneal dialysis, it is dimensionless only by definition. It was developed as a way for measuring the dose of dialysis when they analyzed the data from the National Cooperative Dialysis Study. (Gotch and Sargent (1985). Kidney Int. 28:526-34). In hemodialysis the US National Kidney Foundation Kt/V target is 1.3, so that one can be sure that the delivered dose is at least 1.2; in peritoneal dialysis the target is 2.0/week. (Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis 35 (6 Suppl 2): S 1-140. 2000).

A patient is said to be on stable hemodialysis when they present with a monthly Kt/V_urea> 1.20 for three consecutive months prior to first dosing. In some embodiments of the disclosed methods, uses and kits, the has a monthly Kt/V_urea> 1.20 for three consecutive months prior to first dosing.

Parathyroid hormone (ΡΤΉ) is secreted by the chief cells of the parathyroid glands as a polypeptide containing 84 amino acids. It is involved in the regulation of vitamin D synthesis, serum calcium and serum phosphate. ΡΤΉ undergoes proteolysis to yield N- terminal fragments and longer lived C-terminal and midregion fragments. PTH can be measured in blood serum in these several forms: intact PTH; N-terminal PTH; mid-molecule PTH, and C-terminal PTH. As used herein, the phrase "intact PTH" or "iPTH" refers to 1-84 PTH as well as amino terminally truncated PTH fragments (i.e, large carboxy -terminal PTH fragmetns). (See, e.g., Tanaka et al. (2008) NDT Plusl [Sippl 3]:iii59-iii62). Intact PTH is measured by numerous well-known assays, including, e.g., Elecsys PTH (Roche Diagnostics, Germany); Micro Vue Intact PTH (Quidel Corp., San Diego, CA); DAI Intact-PTH Elisa (Diagnostic Automation Inc., Calabasas, CA), etc. In some embodiments of the disclosed methods, uses and kits, the patient has serum intact PTH (iPTH) levels of less than 100 pg/ml.

As used herein the phrase "bone mineral density" or "BMD" refers to the amount of mineral matter per square centimeter of bone (usually given in g cm^"2, z-score, t-score) as the term is used in clinical practice. BMD is most frequently measured at the hip or lumbar spine to assess bone formation using x-ray absorptiometry (including dual photon absorptiometry (DPA), dual-energy x-ray absorptiometry (DXA) and peripheral dual-energy x-ray absorptiometry (pDXA)). Information on x-ray absorptiometry may be found in, e.g., Link (2012) Radiology 263:3-17. Volumetric BMD is another measure of bone density, which, unlike x-ray absorptiometry, accounts for a bone's volume. Volumetric (total) BMD can be obtained using quantitative computed tomography (QCT) (e.g, peripheral QCT). Information on QCT may be found in, e.g., Engelke et al (2008) J of Clinical Densitometry: Assessment of Skeletal Health, 11 : 123-162 and Muller et al. (1989) Phus Med Biol. 34:741-9. Percentage change from baseline at month X in bone mineral density (BMD), e.g., at the lumbar spine, can be determined as:

% change BMD month X = ^BMD^ ^{" BMD}^ime _{χ 1 00}«>_/ο

BMD_baselme

As used herein the term "improvement" means a meaningful (e.g., statistically meaningful) enhancement in value or quality. In the case of BMD as measured by DXA, an improvement is at least about 0.5% increase above placebo (e.g., at least about 0.5%, at least about 0.75%, at least about 1.0%, at least about 1.25%, at least about 1.5%, at least about 1.75%, etc.). Given the inherent noise in DXA measurement methods, at least about 0.5% increase above placebo is equivalent to about a 1.5% total increase. In some embodiments of the disclosed methods, uses and kits, following treatment with the anti-sclerostin antibody or antigen binding fragment thereof, the patient displays an improvement in lumbar spine bone mineral density (BMD) of at least about 0.5% increase above placebo, as measured by DXA. In some embodiments of the disclosed methods, uses and kits, following treatment with the anti-sclerostin antibody or antigen binding fragment thereof, the patient displays an improvement in volumetric BMD as measured by quantitative computed tomography (QCT). In some embodiments of the disclosed methods, uses and kits, the patient has two evaluable consecutirve vertebral bodies for DXA, i.e., no fractures and no sclerostis.

Bone formation may also be assessed using Positron Emission Tomography with ¹⁸F- fluoride (¹⁸NaF-PET) imaging. More specifically, renal failure produces bone disorders characterized by reduced bone formation and/or impaired mineralization, such as ABD. Bone biopsy with double tetracycline labeling is considered a gold standard for the direct histomorphometric assessment of bone metabolic activity, but it is invasive and complex. Bone turnover markers (BTMs) in serum or urine can provide rapid response in changes in metabolic activity across the whole skeleton, but cannot provide insight into changes that occur at specific sites such as hip or spine. However, ¹⁸NaF-PET is a non-invasive imaging technique that has been developed to measure site-specific bone formation rates, and which can be used to "diagnose" ABD (Frost et al. (201 1) J Bone Miner Res. 26: 1002-11; Messa et al (1993) J Clin Endocrinol Metab. 77:949-55). In some embodiments of the disclosed methods, uses and kits, following treatment with the anti-sclerostin antibody or antigen binding fragment thereof, the patient displays an improvement in hip and lumbar spine bone formation as measured by ¹⁸F-fluoride PET-CT imaging.

A patient having CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, or having CKD and being suspected of developing MBD in the future would be considered in need of treatment with the disclosed sclerostin antagonists (e.g., anti-sclerostin antibodies and antigen-binding fragments thereof). The terms "treatment", "treating" or "treat" refer to both prophylactic or preventative treatment as well as curative or disease modifying treatment, including treatment of patient at risk of contracting MBD or suspected to have contracted MBD as well as patients who are ill or have been diagnosed as suffering from MBD, and includes suppression of clinical relapse. The treatment may be administered to a subject having CKD with evidence of MBD, in order to prevent, cure, delay the onset of, reduce the severity of, or ameliorate one or more symptoms of MBD, or in order to prolong the survival of a subject beyond that expected in the absence of such treatment. The treatment may be administered to a subject having CKD with evidence of MBD to regulate bone mineralization, regulate bone volume, regulate bone turnover, improve bone architecture, increase bone mineral density (BMD) (spine and/or hip), reduce fracture, and/or improve volumetric BMD.

As used herein, a "therapeutically effective amount" refers to an amount of a sclerostin antagonist (e.g., sclerostin inhibitory polynucleotide, sclerostin inhibitory polypeptide, antagonistic anti-sclerostin antibody or antigen-binding fragments thereof, and antagonistic small molecules, e.g., Antibody 1 as set forth in as disclosed in WO09047356, the contents of which are incorporated by reference herein in its entirety) that is effective, upon single or multiple dose administration to a subject (such as a human patient) at treating, preventing, preventing the onset of, curing, delaying, reducing the severity of, ameliorating at least one symptom of a disorder (e.g., CKD with evidence of MBD) or recurring disorder, or prolonging the survival of the subject beyond that expected in the absence of such treatment. When applied to an individual active ingredient (e.g., an anti-sclerostin antibody)

administered alone, the term refers to that ingredient alone. When applied to a combination, the term refers to combined amounts of the active ingredients that result in the therapeutic effect, whether administered in combination, serially or simultaneously.

As used herein, the term "patient" includes any human or nonhuman animal. The term

"nonhuman animal" includes all vertebrates, e.g., mammals and non-mammals, such as nonhuman primates, sheep, dogs, cats, horses, cows, chickens, amphibians, reptiles, etc. In some embodiments of the disclosure, the patient is a human.

Sclerostin Antagonists

The instant methods, kits and uses employ anti-sclerostin antibodies or antigen- binding fragments thereof (e.g., Antibody 1-5 or antigen-binding fragments thereof, preferably Antibody 1 or antigen-binding fragments thereof) for the treatment of CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD. An antibody is a polypeptide comprising a framework region from an immunoglobulin gene or portion thereof that specifically binds and recognizes an epitope, e.g., an epitope found on sclerostin. The term "antibody" as used herein includes whole antibodies and any antigen-binding fragment or single chains thereof. A whole "antibody" is a glycoprotein comprising at least two heavy (H) chains and two light (L) chains inter-connected by disulfide bonds. Each heavy chain is comprised of a heavy chain variable (VH) region and a heavy chain constant region. The heavy chain constant region is comprised of three domains, CHI, CH2 and CH3. Each light chain is comprised of a light chain variable (VL) region and a light chain constant region. The light chain constant region is comprised of one domain, CL. The VL and VH regions can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDR), interspersed with regions that are more conserved, termed framework regions (FR). Each VL and VH is composed of three CDRs and four FRs arranged from amino- terminus to carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The CDRs of the heavy chain are referred to herein as HCDR1, HCDR2 and HCDR3. The CDRs of the light chain are referred to herein as LCDR1, LCDR2, and LCDR3. The variable regions of the heavy and light chains contain a binding domain that interacts with an epitope on an antigen. The constant regions of the antibodies may mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component (Clq) of the classical complement system.

The term "antibody" includes single domain antibodies, maxibodies, nanobodies, peptibodies (Amgen), minibodies, intrabodies, diabodies, triabodies, tetrabodies, v-NAR and bis-scFv (see, e.g., Hollinger & Hudson, Nature Biotechnology, 23, 9, 1126-1136 (2005)). Antigen-binding fragments of antibodies can be grafted into scaffolds based on polypeptides such as Fibronectin type III (Fn3) (see U.S. Pat. No. 6,703,199, which describes fibronectin polypeptide monobodies). Details of various types of antibodies and antigen-binding fragments thereof for use in the disclosed methods may be found in WO09047356.

Also included within the definition of "antibody" are single-chain antibodies.

Although the two domains of the Fv fragment, VL and VH, are coded for by separate genes, they can be joined, using recombinant methods, by a synthetic linker that enables them to be made as a single protein chain in which the VL and VH regions pair to form monovalent molecules (known as single chain Fv (scFv); see e.g., Bird et al., 1988 Science 242:423-426; and Huston et al., 1988 Proc. Natl. Acad. Sci. 85:5879-5883). Such single chain antibodies are also intended to be encompassed within the term "antigen-binding region" of an antibody. A single-chain antibody may comprise the antibody variable regions alone, or in combination, with all or part of the following polypeptide elements: hinge region, CHI, CH2, and CH3 domains of an antibody molecule.

Also included within the definition of "antibody" are antigen-binding fragments of antibodies. It has been shown that the antigen-binding function of an antibody can be performed by fragments of a full-length antibody. Thus, "antigen-binding fragment" refers to one or more fragments of an antibody that retain the ability to specifically bind to an antigen (e.g., an antigen of sclerostin). Antigen-binding fragments include, e.g., but are not limited to, Fab, Fab' and F(ab')₂, Fd, single-chain Fvs (scFv), single-chain antibodies, disulphide-linked Fvs (sdFv) and fragments comprising either a VL or VH domain. Examples include: (i) a Fab fragment, a monovalent fragment consisting of the VL, VH, CL and CHI domains; (ii) a F(ab') ₂ fragment, a bivalent fragment comprising two Fab fragments linked by a disulphide bridge at the hinge region; (iii) a Fd fragment consisting of the VH and CHI domains; (iv) a Fv fragment consisting of the VL and VH domains of a single arm of an antibody, (v) a dAb fragment (Ward et al, Nature 341 : 544-546, 1989; Muyldermans et al, TIBS 24: 230-235, 2001), which consists of a VH domain; and (vi) an isolated complementarity determining region (CDR). Also included within the definition of "antibody" are any combinations of variable regions and hinge region, CHI, CH2, and CH3 domains. Antigen binding fragments can be incorporated into single chain molecules comprising a pair of tandem Fv segments (VH-CH1-VH-CH1) which, together with complementary light chain polypeptides, form a pair of antigen binding regions (Zapata et al, Protein Eng. 8(10): 1057-1062 (1995); and U.S. Pat. No. 5,641,870). Antibody fragments are obtained using conventional techniques known to those of skill in the art, and the fragments are screened for antigen-binding capability in the same manner as are whole antibodies. It will be understood by one skilled in the art that antibodies may undergo a variety of posttranslational modifications. The type and extent of these modifications often depends on the host cell line used to express the protein as well as the culture conditions. Such modifications may include variations in glycosylation, methionine oxidation, diketopiperizine formation, aspartate isomerization and asparagine deamidation. A frequent modification is the loss of a carboxy-terminal basic residue (such as lysine or arginine) due to the action of carboxypeptidases (as described in Harris, RJ. Journal of Chromatography 705: 129-134, 1995). Table 1, infra, provides antibodies for use in the disclosed used, methods and kits that may retain or relinquish the carboxy-terminal lysine.

Antibody constant regions may be of various isotypes. "Isotype" refers to the antibody class (e.g., IgM, IgE, IgG such as IgGi, IgG4 or IgGi) that is provided by the heavy chain constant region genes. In some embodiments of the disclosed methods and uses, the sclerostin antagonist is an anti-sclerostin antibody of the IgGi, IgG₄ or Igd isotype.

The terms "monoclonal antibody" as used herein refer to an antibody molecule derived from a preparation of antibody molecules of single molecular composition. Thus, a monoclonal antibody displays a single binding specificity and affinity for a particular epitope. In some embodiments of the disclosed methods and uses, the sclerostin antagonist is a monoclonal anti-sclerostin antibody.

Chimeric or humanized antibodies of the present disclosure can be prepared using art- recognized techniques employing the sequences of the antibodies and antibody fragments described herein (e.g., see Table 1). DNA encoding the heavy and light chain immunoglobulins can be obtained from the murine hybridoma of interest and engineered to contain non-murine (e.g., human) immunoglobulin sequences using standard molecular biology techniques. For example, to create a chimeric antibody, the murine variable regions can be linked to human constant regions using methods known in the art (see e.g., U.S. Patent No. 4,816,567 to Cabilly et al.). To create a humanized antibody, the murine CDR regions can be inserted into a human framework using methods known in the art. See e.g., U.S. Patent No. 5,225,539 to Winter, and U.S. Patent Nos. 5,530,101; 5,585,089; 5,693,762 and 6, 180,370 to Queen et al. In some embodiments of the disclosed methods and uses, the sclerostin antagonist is a chimeric or humanized anti-sclerostin antibody

The term "human antibody", as used herein, is intended to include antibodies having variable regions in which both the framework and CDR regions are derived from sequences of human origin. Furthermore, if the antibody contains a constant region, the constant region also is derived from such human sequences, e.g., human germline sequences, or mutated versions of human germline sequences or antibody containing consensus framework sequences derived from human framework sequences analysis as described in Knappik, et al. (2000. J Mol Biol 296, 57-86). The human antibodies for use in the disclosed methods may include amino acid residues not encoded by human sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo). However, the term "human antibody", as used herein, is not intended to include antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, have been grafted onto human framework sequences, which are instead referred to as "chimeric" antibodies and/or "humanized" humanized antibodies. In some embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the sclerostin antagonist is a human antibody.

The term "human monoclonal antibody" refers to antibodies displaying a single binding specificity and that have variable regions in which both the framework and CDR regions are derived from human sequences. In one embodiment, the human monoclonal antibodies are produced by a hybridoma which includes a B cell obtained from a transgenic nonhuman animal, e.g., a transgenic mouse, having a genome comprising a human heavy chain transgene and a light chain transgene fused to an immortalized cell. Such animals are available from the companies Medarex and Kirn. In another embodiment, the human monoclonal antibodies are produced by a transgenic mouse having human immunoglobulin genes. In some embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the sclerostin antagonist is a human monoclonal antibody.

The term "recombinant human antibody", as used herein, includes all human antibodies that are prepared, expressed, created or isolated by recombinant means, such as antibodies isolated from an animal (e.g., a mouse) that is transgenic or transchromosomal for human immunoglobulin genes or a hybridoma prepared therefrom, antibodies isolated from a host cell transformed to express the human antibody, e.g., from a transfectoma, antibodies isolated from a recombinant, combinatorial human antibody library, and antibodies prepared, expressed, created or isolated by any other means that involve splicing of all or a portion of a human immunoglobulin gene, sequences to other DNA sequences. Such recombinant human antibodies have variable regions in which the framework and CDR regions are derived from human germline immunoglobulin sequences. In certain embodiments, however, such recombinant human antibodies can be subjected to in vitro mutagenesis (or, when an animal transgenic for human Ig sequences is used, in vivo somatic mutagenesis) and thus the amino acid sequences of the VH and VL regions of the recombinant antibodies are sequences that, while derived from and related to human germline VH and VL sequences, may not naturally exist within the human antibody germline repertoire in vivo. In some embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the sclerostin antagonist is a recombinant human antibody.

As used herein, an antibody that "specifically binds to a sclerostin polypeptide" is intended to refer to an antibody that binds to sclerostin polypeptide with a K_D of about 1 x 10^" ⁸ M or less, about 1 x 10^"9 M or less, or about 1 x 10^"10 M or less. An antibody that "cross- reacts with an antigen other than sclerostin" (or the like) is intended to refer to an antibody that binds to that antigen with a KD of about 0.5 x 10^"8 M or less, about 5 x 10^"9 M or less, or about 2 x 10^"9 M or less. An antibody that "does not cross-react with a particular antigen" (or the like) is intended to refer to an antibody that binds to a particular antigen with a K_D of about 1.5 x 10^"8 M or greater, or a K_D of between about 5 x 10^"8 M and about 10 x 10^"8 M, or about 1 x 10^"7 M or greater. Antibodies that do not cross-react with a particular antigen exhibit a lack of significant binding against that particular antigen in standard binding assays. In certain embodiments of the disclosed methods and uses, the anti-sclerostin antibody specifically binds sclerostin. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the anti-sclerostin antibody specifically binds sclerostin and does not cross react with an antigen other than sclerostin. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the anti- sclerostin antibody specifically binds sclerostin and does not cross react with Dan or Gremlin.

In some embodiments of the disclosed methods, compositions, uses and kits, the anti- sclerostin antibody competes with Antibody 1, 2, 3, 4 or 5 for binding to sclerostin. Competing antibodies typically recognize the same epitope. Thus, e.g., in some embodiments of the disclosed methods, compositions, uses and kits, the anti-sclerostin antibody binds the same epitope as that which is bound by Antibody 1, 2, 3, 4, or 5. The sclerostin epitopes bound by Antibodies 1, 2, 3, 4 and 5 are set forth, e.g., in US 7758858, US7381409, US7578999, WO05003158, WO06119062, WO06119107, WO08115732, and US7744874, the contents of which are incorporated by reference herein in their entirety.

The terms "about", "approximately", and the like, when preceding a list of numerical values or range, refer to each individual value in the list or range independently as if each individual value in the list or range was immediately preceded by that term. The term "about", "approximately", and the like, in relation to a numerical value x means, for example, +/-10%.

As used herein, "significant" in relation to a numerical value refers to statistical significance.

As used herein, "a cell-based Wnt signaling assay" is intended to refer to a cell-based (e.g., HEK293) super top flash (STF) assay. Such assay is described in more details in WO09047356. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the antibodies have an IC₅₀ less than about ΙμΜ, preferably less than about 100 nM and more preferably less than about 20 nM as measured in a cell-based Wnt signaling assay in HEK293 cell lines in the presence of sclerostin.

In one embodiment, anti-sclerostin antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses have the ability to reverse sclerostin inhibition of in vitro bone mineralization. In a related embodiment, they have the ability to reverse sclerostin inhibition of the Wnt-1 mediated signaling pathway. In another related embodiment, they disrupt sclerostin LRP6 binding and can block the inhibitory effect that sclerostin has at high doses on BMP induced Smadl phosphorylation.

Sclerostin inhibits Wnt 1 -mediated activation of STF (Supertopflash, reporter readout for canonical Wnt signaling) in HEK293 cells. In some embodiments, the antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses restore the Wnt signaling reporter readout in a highly reproducible manner.

The observed inhibitory effect of the antibodies according to the disclosure on sclerostin action in the Wnt signaling reporter assay in non-osteoblastic cells has been shown to translate into induction of bone formation responses due to sclerostin inhibition in vivo. Indeed, in vivo experiments in aged rodents show that the antibodies according to the disclosure promote strong bone anabolism. The bone mass increase reached the effect level of daily intermittent treatment with extremely high anabolic doses of parathyroid hormone (which was used as a positive control). Therefore, according to another embodiment, the antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses have affinities to sclerostin in the low pM range (preferably about 100 pM or less, preferably about 50 pM or less, preferably about 10 pM or less, more preferably about 1 pM or less) and inhibit sclerostin impact on wnt signalling with an IC₅₀ around about 10 nM.

As used herein, a "BMP2-induced mineralization assay" is intended to refer to an assay the measures restoration of BMP2 induced mineralisation in the presence of sclerostin in a cell-based assay (e.g., in MC3T3 cells). Such assay is described in more details in WO09047356. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the antibodies have an IC50 less than about 1 μΜ, preferably less than about 500 nM and more preferably less than about 200 nM as measured in BMP2- induced mineralization assay in MC3T3 cells in the presence of sclerostin.

As used herein, a "Smadl phosphorylation assay" is intended to refer to an assay the measures restoration of BMP6 induced Smadl phosphorylation in the presence of sclerostin in a cell based assay (e.g., in MC3T3-E1 cells). Such assay is described in more details in WO09047356. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the antibodies have an IC50 less than about 1 μΜ, preferably less than about 500 nM, preferably less than about 200 nM as measured in BMP6 Smadl phosphorylation assay in MC3T3-E1 cell line in the presence of sclerostin

As used herein, an "LPJWsclerostin ELISA" is intended to refer to an ELISA assay used to measure the interaction of sclerostin with LRP-6. Such assay is described in more details in WO09047356. In certain embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the antibodies have an IC₅₀ less than about 1 μΜ, preferably less than about lOOnM, more preferably less than about 10 nM (e.g., about 6 nM), more preferably less than about 5nM, more preferably less than about 3 nM as measured in LPJWsclerostin ELISA. In certain embodiments of the disclosed methods and uses, the antibodies have an IC50 of about 5.8 nM, about 6.0 nM, about 6.5 nM, about 7.0 nM, about 9.6 nM, about 10.6 nM, about 12.1 nM, or about 19.4 nM in a in LPJWsclerostin ELISA.

An antibody that "inhibits" one or more sclerostin functional properties (e.g., biochemical, immunochemical, cellular, physiological or other biological activities, or the like, as described above, e.g., BMP-2 induced mineralization) as determined according to methodologies known to the art and described herein, will be understood to relate to a statistically significant decrease in the particular activity relative to that seen in the absence of the antibody (or when a control antibody of irrelevant specificity is present). An antibody that inhibits sclerostin activity effects such a statistically significant decrease by at least 10% of the measured parameter, by at least 50%, 80% or 90%, and in certain embodiments an antibody used in the disclosed methods, pharmaceutical compositions, kits and uses may inhibit greater than 95%, 98% or 99% of sclerostin functional activity.

The term "K_assoc" or "K_a", as used herein, is intended to refer to the association rate of a particular antibody-antigen interaction, whereas the term "K_di_s" or "K_D," as used herein, is intended to refer to the dissociation rate of a particular antibody-antigen interaction. The term "KD", as used herein, is intended to refer to the dissociation constant, which is obtained from the ratio of K_d to K_a (i.e. K_d/K_a) and is expressed as a molar concentration (M). KD values for antibodies can be determined using methods well established in the art. A method for determining the K_D of an antibody is by using surface plasmon resonance, or using a biosensor system, such as a Biacore^® system, KinExA-based system, Electrochemiluminescene (BioVeris), Solution Equilibrium Titration, Receptor Binding Inhibition Potency Assay, etc. These assays are set forth in detail in WO09047356, WO06119107 and US7744874.

As used herein, "affinity" refers to the strength of interaction between an antibody and an antigen at a single antigenic site. Within each antigenic site, the variable region of the antibody "arm" interacts through weak non-covalent forces with antigen at numerous sites; the more interactions, the stronger the affinity.

As used herein, "avidity" refers to an informative measure of the overall stability or strength of the antibody-antigen complex. It is controlled by three major factors: antibody affinity; the valence of both the antigen and antibody; and the structural arrangement of the interacting parts. Ultimately these factors define the specificity of the antibody, that is, the likelihood that the particular antibody is binding to a precise antigen epitope.

As used herein, "high affinity" for an IgG antibody refers to an antibody having a KD of about 10^"8 M or less, about 10^"9 M or less, or about 10^"10 M or less for a target antigen. However, "high affinity" binding can vary for other antibody isotypes. For example, "high affinity" binding for an IgM isotype refers to an antibody having a K_D of about 10^"7 M or less, or about 10^"8 M or less. In some embodiments of the disclosed methods, pharmaceutical compositions, kits and uses, the sclerostin antagonist is high affinity anti-sclerostin antibody.

In some embodiments, antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses have a K_D less than about 10 nM, less than about 1 nM, less than about 100 pM, less than about 50 pM, or less than about 25 pM, e.g., about 15-25 pM, e.g., about 21 pM +/- 4 pM as determined by surface plasmon resonance. In some embodiments, antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses have a KD of about 0.5 to about 10 pM, e.g, about 0.6 pM, about 1 pM, about 3 pM, about 4 pM, or about 6 pM as measured in a KinExA-based determination experiment as set forth in Example

10 of WO06119107. In some embodiments, antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses have a K_D of about 0.2 to about 2.5 pM, e.g, about 0.3 pM, about 0.6 pM, about 2.2 pM as measured in a KinExA-based determination experiment as set forth in Example 3 of US7744874.

Various sclerostin antagonists (e.g., anti-sclerostin antibodies) are disclosed in WO09047356, WO2000/32773, WO2006102070, US20080227138, US20100028335, US 20030229041, WO2005003158, WO2009039175 WO2009079471, WO03106657, WO2006119062, WO08115732, WO2005/014650, WO2005/003158, WO2006/119107, WO2008/061013, WO2008/133722, WO2008/115732, US7592429, US7879322, US7744874, the contents of which are incorporated by reference herein in their entirety. Any (or several) of the sclerostin antagonists disclosed in these references may be used in the disclosed methods, pharmaceutical compositions, kits and uses. Further anti-sclerostin antibodies that may be used in the disclosed methods and uses include those known as AMG167 and AMG785 (Amgen) (see, e.g., Padhi et al. (2011) J. Bone Miner. Res. 26: 19-26) and those found in Ominsky et al. (2010) J. Bone Min. Res (Epub Dec. 2); Li et al. (2010) J. Bone Miner. Res. 25:2371-80; Li et al. (2009) J. Bone Miner Res. 24:578-88; Ominsky et al. (2010) J. Bone Miner Res. 25:948-59. In some embodiments, an anti-sclerostin antibody for use in the disclosed methods and uses binds to an epitope of sclerostin described in WO2006/119062, WO2005014650 or WO2005003158 or WO09047356.

Preferred anti-sclerostin antibodies and antigen-binding fragments thereof for use in the disclosed methods, pharmaceutical compositions, kits and uses are found in WO09047356 (equivalent to US7879322), WO06119107 (equivalent to US7872106 and US 7592429) and WO08115732 (equivalent to US7744874), e.g.:

Sequence and Designation for Sequence and Designation of this Disclosure Reference Publications

Antibody 1 WO09047356

Heavy chain (H) SEQ ID NO:2 (with or without the SEQ ID NO: 114

19 amino acid signal peptide)

Light chain (L) SEQ ID NO: 3 (with or without 20 SEQ ID NO: 125

amino acid signal peptide)

V_H SEQ ID NO:4 SEQ ID NO:70

V_L SEQ ID NO:5 SEQ ID NO:81

HCDR1 SEQ ID NO: 6 SEQ ID NO:4

HCDR2 SEQ ID NO: 7 SEQ ID NO: 15

HCDR3 SEQ ID NO: 8 SEQ ID NO:26

LCDR1 SEQ ID NO:9 SEQ ID NO:37

LCDR2 SEQ ID NO: 10 SEQ ID NO:48

LCDR3 SEQ ID NO: 11 SEQ ID NO:59

V_L SEQ ID NO:45 SEQ ID NO: 18

HCDRl SEQ ID NO:46 SEQ ID NO:26

HCDR2 SEQ ID NO:47 SEQ ID NO:27

HCDR3 SEQ ID NO:48 SEQ ID NO:28

LCDRl SEQ ID NO:49 SEQ ID NO:29

LCDR2 SEQ ID NO:50 SEQ ID NO:30

LCDR3 SEQ ID N0:51 SEQ ID N0:31

Table 1 : Preferred anti-sclerostin antibodies for use in the disclosed methods, pharmaceutical compositions, kits and uses. The CDR regions in Table 1 are delineated using the Kabat system (Kabat, E. A., et al, 1991 Sequences of Proteins of Immunological Interest, Fifth Edition, U.S. Department of Health and Human Services, NIH Publication No. 91-3242).

Given that the antibodies used in the disclosed methods, pharmaceutical compositions, kits and uses can bind to sclerostin and that antigen-binding specificity is provided primarily by the CDR1, 2 and 3 regions, the VH CDR1, 2 and 3 sequences and VL CDR1, 2 and 3 sequences can be "mixed and matched" (i.e., CDRs from different antibodies can be mixed and matched), although each antibody contains a HCDRl, HCDR2 and HCDR3, as well as a LCDRl, LCDR2 and LCDR3 to create other anti-sclerostin antibodies. Sclerostin binding of such "mixed and matched" antibodies can be tested using the binding assays described in WO2009/047356. When V_H CDR sequences are mixed and matched, the HCDRl, HCDR2 and/or HCDR3 sequence from a particular VH sequence should be replaced with a structurally similar CDR sequence(s). Likewise, when VL CDR sequences are mixed and matched, the LCDRl, LCDR2 and/or LCDR3 sequence from a particular VL sequence should be replaced with a structurally similar CDR sequence(s). It will be readily apparent to the ordinarily skilled artisan that novel VH and VL sequences can be created by substituting one or more VH and/or VL CDR region sequences with structurally similar sequences from the CDR sequences shown herein (e.g., Table 1) for monoclonal antibodies that may be used in the disclosed methods, pharmaceutical compositions, kits and uses.

Particularly preferred antibodies for use with the disclosed methods, pharmaceutical compositions, kits and uses are an anti-sclerostin antibodies disclosed in WO09047356 (the complete contents of which are incorporated herein by reference). In one embodiment, the anti-sclerostin antibody for use in the disclosed methods and uses is found in WO09047356 and referred to herein as "Antibody 1" (See Table 1). Antibody 1 has a VH domain with amino acid SEQ ID NO: 4 and a VL domain with amino acid SEQ ID NO:5. Other anti- sclerostin antibodies useful with the present disclosure may include one or more (1, 2, 3, 4, 5 or 6) CDRs from Antibody 1. The CDRs in the heavy chain are SEQ ID NOs: 6-8. The CDRs in the light chain are SEQ ID N0s:9-11. The Antibody 1 VH CDRS may be expressed along with VH framework regions (e.g., VH human framework regions), the Antibody 1 VL CDRS may be expressed along with VL framework regions (e.g., VL human framework regions), the Antibody 1 VH and VL CDRS may be expressed along with VH and VL framework regions (e.g., VH and VL human framework regions) (e.g., human or humanized), and the Antibody 1 heavy and light domains may be expressed as SEQ ID NOs:2 and 3.

Disclosed herein are methods, uses and kits for treating CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, by inhibiting sclerostin activity. Disclosed herein are also methods of reducing FGF23 levels in a patient in need thereof (e.g., a CKD patient), comprising administering a therapeutically effective amount of an anti- sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient. Disclosed herein are also methods of increasing serum PTH levels in a patient in need thereof (e.g., an ABD patient that is not resistant to PTH), comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient. Disclosed herein are also methods of reducing serum phosphate levels in a patient in need thereof (e.g., a CKD patient), comprising administering a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, to said patient.

In some of the disclosed, methods, uses and kits, the sclerostin antagonist is an anti- sclerostin antibody or antigen-binding fragment thereof. In some embodiments, the anti- sclerostin antibody or antigen-binding fragment thereof: binds to human sclerostin with a K_D less than 10 nM as determined by surface plasmon resonance or a biosensor system; has an IC₅₀ less than 1 μΜ as measured in a cell-based Wnt signaling assay in HEK293 cell lines in the presence of sclerostin; has an IC₅₀ less than 1 μΜ as measured in BMP2-induced mineralization assay in MC3T3 cells in the presence of sclerostin; has an IC50 less than 1 μΜ as measured in LRP6/sclerostin ELISA; and/or has an IC50 less than 1 μΜ as measured in BMP6 Smadl phosphorylation assay in MC3T3-E1 cell line in the presence of sclerostin.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:4; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 5; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 4 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:5; or an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three Complementarity -Determining Regions (CDRs) of the amino acid sequence set forth as SEQ ID NO:4 and the three CDRs of the amino acid sequence set forth as SEQ ID NO: 5.

In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:4 are set forth in SEQ ID NO:6, SEQ ID NO:7, and SEQ ID NO:8. In further embodiments the three CDRs of the amino acid sequence set forth as SEQ ID NO: 5 are set forth in SEQ ID NO: 9, SEQ ID NO: 10, and SEQ ID NO: 11.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 14; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 15; an anti-sclerostin antibody or antigen- binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 14 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 15; or an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three CDRs of the amino acid sequence set forth as SEQ ID NO: 14 and the three CDRs of the amino acid sequence set forth as SEQ ID NO: 15.

In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO: 14 are set forth in SEQ ID NO: 16, SEQ ID NO: 17, and SEQ ID NO: 18. In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO: 15 are set forth in SEQ ID NO: 19, SEQ ID NO:20, and SEQ ID NO:21.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:24; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 25; an anti-sclerostin antibody or antigen- binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:24 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:25; or an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three CDRs of the amino acid sequence set forth as SEQ ID NO:24 and the three CDRs of the amino acid sequence set forth as SEQ ID NO:25.

In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:24 are set forth in SEQ ID NO:26, SEQ ID NO:27, and SEQ ID NO:28. In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO: 25 are set forth in SEQ ID NO:29, SEQ ID NO:30, and SEQ ID NO:31.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:34; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 35; an anti-sclerostin antibody or antigen- binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:34 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:35; or an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three CDRs of the amino acid sequence set forth as SEQ ID NO:34 and the three CDRs of the amino acid sequence set forth as SEQ ID NO:35.

In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:34 are set forth in SEQ ID NO:36, SEQ ID NO:37, and SEQ ID NO:38. In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:35 are set forth in SEQ ID NO:39, SEQ ID NO:40, and SEQ ID NO:41.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:44; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 45; an anti-sclerostin antibody or antigen- binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:44 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:45; or an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three CDRs of the amino acid sequence set forth as SEQ ID NO:44 and the three CDRs of the amino acid sequence set forth as SEQ ID NO:45.

In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:44 are set forth in SEQ ID NO:46, SEQ ID NO:47, and SEQ ID NO:48. In further embodiments, the three CDRs of the amino acid sequence set forth as SEQ ID NO:45 are set forth in SEQ ID NO:49, SEQ ID NO:50, and SEQ ID NO:51.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is an anti-sclerostin antibody. In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody is a chimeric antibody, a humanized antibody, or a human antibody. In some of the above methods and uses, the anti-sclerostin antibody is a monoclonal anti-sclerostin antibody or a human recombinant anti-sclerostin antibody. In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody is of the IgGi, IgG₂ or IgG₄ isotype.

In some of the disclosed, methods, uses and kits, the anti-sclerostin antibody or antigen-binding fragment thereof is an antigen-binding fragment of an antibody. In some of the disclosed, methods, uses and kits, the antigen-binding fragment comprises an F(ab')2, Fab, Fab', Fv, Fc or Fd fragment.

Pharmaceutical Compositions

In practicing the methods of treatment or uses of the present disclosure, a

therapeutically effective amount of at least one an anti-sclerostin antibody or antigen-binding fragment thereof is administered to a patient, e.g., a mammal (e.g., a human), having CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD.

An anti-sclerostin antibody or antigen-binding fragment thereof, such as Antibody 1, 2, 3, 4 or 5, may be administered in accordance with the methods and uses of the disclosure either alone or in combination with other agents (e.g., one or more additional agents) and therapies, such as, e.g., in combination with additional sclerostin antagonists. When coadministered with one or more additional agents, the anti-sclerostin antibody or antigen- binding fragment thereof may be administered either simultaneously with the other agent, or sequentially. If administered sequentially, the attending physician will decide on the appropriate sequence of administering the anti-sclerostin antibody in combination with other agents. Additional agents for use in combination with the disclosed anti-sclerostin antibody or antigen-binding fragment thereof include, e.g., bone anabolics and bone anti-resorptives, and combinations thereof. A bone anabolic agent may be a RANKL antibody (such as denosumab), parathyroid hormone (PTH), a PTH fragment or a PTH derivative e.g. PTH (1- 84) (such as Preos®), PTH (1-34) (such as Forteo®), PTH (1-36), PTH (1-38), PTH (1- 31)NH₂ or PTS 893. The PTH (e.g., PTH (1-36), PTH (1-38)) may be administered orally in combination with a suitable oral carrier, such as those set forth in U.S. 5,773,647 (herein incorporated by reference in its entirety), e.g., N-(5-chlorosalicyloyl)-8-aminocaprylic acid (5- CNAC) and pharmaceutically acceptable salts (e.g., the disodium salt of 5-CNAC) and esters thereof. Alternavely (or in addition), a bone resorption inhibitor may be a bisphosphonate (e.g., Fosamax® (alendronate), Actonel® (risedronate sodium), Boniva/Bonviva®

(ibandronic acid), Zometa® (zoledronic acid), Aclasta®/Reclast® (zoledronic acid), olpadronate, neridronate, etidronate, clodronate, skelid, bonefos), Selected Estrogen Receptor Modulator (SERMs, such as raloxifene, lasofoxifene, bazedoxifene, arzoxifene, FC1271, Tibolone (Livial ®)), estrogen and calcitonin (e.g., a salmon calcitonin (sCT), such as Miacalcin®). Other variants of bone resorption inhibitors are disclosed in WO01/97788 and may be used in the invention. Additional agents for use in combination with the disclosed anti-sclerostin antibody or antigen-binding fragment thereof include, e.g., progestin, androgen, lithium chloride, fluoride, and glucocorticosteroids (e.g., prednisone).

In one embodiment, the bone resorption inhibitor is a bisphosphonate. In a further embodiment, the bone resorption inhibitor is a nitrogen-containing bisphosphonate. It is preferred that the bone resorption inhibitor is zoledronic acid for use in, such as

Aclasta®/Reclast®.

When a therapeutically effective amount of an anti-sclerostin antibody or antigen- binding fragment thereof is administered orally, the binding agent will be in the form of a tablet, capsule, powder, solution or elixir. When administered in tablet form, the

pharmaceutical composition of the disclosure may additionally contain a solid carrier such as a gelatin or an adjuvant. When administered in liquid form, a liquid carrier such as water, petroleum, oils of animal or plant origin such as peanut oil (exercising caution in relation to peanut allergies), mineral oil, soybean oil, or sesame oil, or synthetic oils may be added. The liquid form of the pharmaceutical composition may further contain components such as physiological saline solution, dextrose or other saccharide solution, or glycols such as ethylene glycol, propylene glycol, or polyethylene glycol.

When a therapeutically effective amount of an anti-sclerostin antibody or antigen- binding fragment thereof is administered by intravenous, cutaneous or subcutaneous injection, the sclerostin antagonist will be in the form of a pyrogen-free, parenterally acceptable solution. A pharmaceutical composition for intravenous, cutaneous, or subcutaneous injection may contain, in addition to the sclerostin antagonist, an isotonic vehicle such as sodium chloride, Ringer's, dextrose, dextrose and sodium chloride, lactated Ringer's, or other vehicle as known in the art.

Pharmaceutical compositions for use in the disclosed methods may be manufactured in conventional manner. In one embodiment, the pharmaceutical composition is preferably provided in lyophilized form. For immediate administration it is dissolved in a suitable aqueous carrier, for example sterile water for injection or sterile buffered physiological saline. If it is considered desirable to make up a solution of larger volume for administration by infusion rather than a bolus injection, may be advantageous to incorporate human serum albumin or the patient's own heparinized blood into the saline at the time of formulation. The presence of an excess of such physiologically inert protein prevents loss of antibody by adsorption onto the walls of the container and tubing used with the infusion solution. If albumin is used, a suitable concentration is from about 0.5 to about 4.5% by weight of the saline solution. Other formulations comprise liquid or lyophilized formulation.

The appropriate dosage will, of course, vary depending upon, for example, the particular sclerostin antagonist to be employed, the host, the mode of administration and the nature and severity of the condition being treated, and on the nature of prior treatments that the patient has undergone. Ultimately, the attending health care provider will decide the amount of the sclerostin antagonist with which to treat each individual subject. In some embodiments, the attending health care provider may administer low doses of the sclerostin antagonist and observe the subject's response. In other embodiments, the initial dose(s) of sclerostin antagonist administered to a subject are high, and then are titrated downward until signs of relapse occur. Larger doses of the sclerostin antagonist may be administered until the optimal therapeutic effect is obtained for the subject, and at that point the dosage is not generally increased further.

An anti-sclerostin antibody or antigen-binding fragment is conveniently administered parenterally, intravenously, e.g. into the antecubital or other peripheral vein, intramuscularly, or subcutaneously. The duration of intravenous (i.v.) therapy using a pharmaceutical composition of the present disclosure will vary, depending on the severity of the disease being treated and the condition and personal response of each individual patient. Also contemplated is subcutaneous (s.c.) therapy using a pharmaceutical composition of the present disclosure. The health care provider will decide on the appropriate duration of i.v. or s.c. therapy and the timing of administration of the therapy, using the pharmaceutical composition of the present disclosure.

Satisfactory results (treatment, prophylaxis, delay of onset of symptoms, etc.) are generally indicated to be obtained at dosages from about 0.05 mg to about 30 mg per kilogram body weight, more usually from about 0.1 mg to about 20 mg per kilogram body weight. The frequency of dosing may be in the range from about once per day up to about once every three months, e.g., in the range from about once every 2 weeks up to about once every 12 weeks, e.g., once every four to eight weeks. The dosing frequency will depend on, inter alia, the phase of the treatment regimen. In some embodiments, the anti-sclerostin antibody dose may be from about 1 mg/kg to about 500 mg/kg, or about 10 mg/kg to about 400 mg/kg, or about 100 mg/kg to about 350 mg/kg, or about 200 mg/kg to about 300 mg/kg.

Antibody is usually administered on multiple occasions. Intervals between single dosages can be, for example, weekly, monthly, every three months or yearly. Intervals can also be irregular as indicated by measuring blood levels of antibody to the target antigen in the patient. In some methods, dosage is adjusted to achieve a plasma antibody concentration of about 1 to about 1000 μg/ml and in some methods about 25 to about 300 μg/ml.

Alternatively, antibody can be administered as a sustained release formulation, in which case less frequent administration is required. Dosage and frequency vary depending on the half-life of the antibody in the patient. In general, human antibodies show the longest half-life, followed by humanized antibodies, chimeric antibodies, and nonhuman antibodies. Pegylation technology may be used to increase the antibody half-life. The dosage and frequency of administration can vary depending on whether the treatment is prophylactic or therapeutic. In prophylactic applications, a relatively low dosage is administered at relatively infrequent intervals over a long period of time. Some patients continue to receive treatment for the rest of their lives. In therapeutic applications, a relatively high dosage at relatively short intervals is sometimes required until progression of the disease is reduced or terminated or until the patient shows partial or complete amelioration of symptoms of disease. Thereafter, the patient can be administered a prophylactic regime.

Actual dosage levels of the active ingredients in the pharmaceutical compositions of the present disclosure may be varied so as to obtain an amount of the active ingredient which is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient. The selected dosage level will depend upon a variety of pharmacokinetic factors including the activity of the particular compositions of the present disclosure employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion of the particular compound being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compositions employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts.

For some anti-sclerostin antibodies, e.g., Antibody 1, 2, 3, 4 or 5, the dose may be about 5 mg/kg to about 300 mg/kg, or about 10 mg/kg to about 200 mg/kg, or about 20 mg/kg to about 100 mg/kg, about 10 mg/kg to about 40 mg/kg, or about 30 mg/kg to about 50 mg/kg. In preferred embodiments, the anti-sclerostin antibody, e.g., Antibody 1, may be administered as about 10 mg/kg, about 15 mg/kg, about 20 mg/kg, about 25 mg/kg, about 30 mg/kg, about 35 mg/kg, about 40 mg/kg, about 45 mg/kg, about 50 mg/kg, about 75 mg/kg, about 100 mg/kg, about 125 mg/kg, or about 150 mg/kg. In some embodiments, the anti-sclerostin antibody, e.g., Antibody 1, 2, 3, 4 or 5, is administered subcutaneously as about 0.1, about 0.3, about 1, about 3, about 5, about 10, or about 20 mg/kg or intravenously as about 1, about 5, about 10 or about 20 mg/kg. In some embodiments, the anti-sclerostin antibody, e.g., Antibody 1, 2, 3, 4 or 5, is administered daily, twice in a week, weekly, every other week, monthly (every 4 weeks), every other month (every 8 weeks), quarterly, every six months, or yearly. In some embodiments, the anti-sclerostin antibody, e.g., Antibody 1, 2, 3, 4 or 5, is administered singly (i.e., only once) or multiply.

"mg/kg" means mg drug per kg body weight of the patient to be treated.

In one embodiment, the total dose of anti-sclerostin antibody given to a patient over the course of a year may be about 500 mg to about 50,000 mg, or about 1000 mg to about 10,000 mg.

In some methods, pharmaceutical compositions, kits and uses, two or more anti- sclerostin antibodies, e.g., with the same or with different binding specificities (e.g., binding the same epitope but having a different binding affinity or binding a different epitope) are administered simultaneously or sequentially (with or without additional agents), in which case the dosage of each antibody administered falls within the ranges indicated.

In some of the disclosed, methods, uses and kits, the sclerostin antagonist is administered with at least one additional agent selected from the group consisting of a bisphosphonate (zoledronic acid, alendronate, risedronate), denusomab/Prolia, estrogen, tibolone, progestin, androgen, a PTH or ΡΤΉ analog, lithium chloride, fluoride,

glucocorticosteroids (e.g., prednisone), a sclerostin antagonist, and SERMs (raloxifene, tamoxifen); strontium ranelate and cathepsin K inhibitors.

Kits and Articles of Manufacture

Disclosed herein are also kits (i.e., an article of manufacture) useful for treating a patient having CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD. Such kits may comprise at least one anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1, or a pharmaceutical composition comprising at least one one anti-sclerostin antibody or antigen-binding fragment thereof, e.g., Antibody 1. Such kits may comprise means for administering the sclerostin antagonist (e.g., a syringe, an autoinjector or a prefilled pen) and instructions for use. These kits may contain additional therapeutic agents for treating CKD with evidence of MBD, for delivery in combination with the enclosed sclerostin antagonist(s), e.g., an anti-sclerostin antibody or fragment thereof, e.g., Antibody 1, 2, 3, 4 or 5, preferably Antibody 1.

Accordingly, provided herein are kits for use in treating a patient having CKD with evidence of MBD, including patients having an actual diagnosis of CKD-MBD, e.g., a stage 3-5 CKD patient (e.g., CKD-5D patient) having ROD, such as ABD, comprising: a) a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof selected from the group consisting of Antibody 1, Antibody 2, Antibody 3, Antibody 4 and Antibody 5; b) optionally, means for administering said anti-sclerostin antibody or antigen binding fragment thereof to the patient; c) optionally, at least one additional agent selected from the group consisting of a bisphosphonate (zoledronic acid, alendronate, risedronate), denusomab/Prolia, estrogen, tibolone, progestin, androgen, a PTH or PTH analog, lithium chloride, fluoride, glucocorticosteroids (e.g., prednisone), a sclerostin antagonist, and SERMs (raloxifene, tamoxifen); strontium ranelate and cathepsin K inhibitors; and d) instructions for administering the anti-sclerostin antibody or antigen binding fragment thereof to the patient.

General

In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen-binding fragment thereof binds to human sclerostin with a K_D less than 10 nM as determined by surface plasmon resonance or a biosensor system; has an IC₅₀ less than

1 uM as measured in a cell-based Wnt signaling assay in HEK293 cell lines in the presence of sclerostin; has an IC₅₀ less than 1 uM as measured in BMP2-induced mineralization assay in MC3T3 cells in the presence of sclerostin; has an IC50 less than 1 uM as measured in

LRP6/sclerostin ELISA; and/or has an IC50 less than 1 uM as measured in BMP6 Smadl phosphorylation assay in MC3T3-E1 cell line in the presence of sclerostin.

In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen binding fragment thereof is selected from the group consisting of: an anti- sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:4; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:5; an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO: 4 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:5; and an anti-sclerostin antibody or antigen- binding fragment thereof comprising the three Complementarity-Determining Regions (CDRs) of the amino acid sequence set forth as SEQ ID NO:4 and the three CDRs of the amino acid sequence set forth as SEQ ID NO:5.

In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen binding fragment thereof comprises the three CDRs set forth in SEQ ID NO:6, SEQ ID NO:7, and SEQ ID NO:8. In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen binding fragment thereof comprises the three CDRs set forth in SEQ ID NO: 9, SEQ ID NO: 10, and SEQ ID NO: 11. In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen binding fragment thereof an anti-sclerostin antibody. In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody is a chimeric antibody, a humanized antibody, or a human antibody. In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody is a monoclonal anti-sclerostin antibody or a human recombinant anti-sclerostin antibody, e.g, of the IgGi, Igd or IgG4 isotype. In some embodiments of the disclosed methods, uses or kits, the anti-sclerostin antibody or antigen binding fragment thereof is an antigen-binding fragment of an antibody, e.g., a F(ab')2, Fab, Fab', Fv, Fc or Fd fragment.

All patents, published patent applications, publications, references and other material referred to in this disclosure are incorporated by reference herein in their entirety. Examples

Example 1: Study A2101

In study A2101, Antibody 1 was administered i.v. to healthy postmenopausal women with low bone mineral density (T-score of >-2.5 and <-1.0 at either lumbar spine or total hip determined by DXA) to study safety, tolerability, and pharmacokinetic/ pharmacodynamic (PK PD) data after single escalating doses of Antibody 1 ranging from 0.1 mg/kg, 0.5 mg/kg, 2.5 mg/kg, 10 mg/kg to 20 mg/kg. Study A2101) was completed as planned and met its primary objective. Antibody 1 at all dose levels (0.1 to 20mg/kg) was safe and well tolerated.

With regard to efficacy, Antibody 1 led to dose related increases in bone formation markers (PINP, OC, BSAP) and a decrease in the resorption marker CTX-1 (Table 2).

Table 2: Table X Mean percent change from baseline in bone formation biomarkers PINP, OC, BSAP, and bone resorption biomarker CTX-1

At the highest dose levels (10 & 20 mg/kg) significant increases in PINP and OC vs. placebo were observed, and at the 20 mg/kg dose level the increase in bone mineral density

(BMD) at the lumbar spine was greater than 2.5%, while a decrease was observed in the placebo group (Figure 1). The mean percent change in lumbar spine BMD with 20 mg/kg BPS804 was 2.8% and 3.7% at Day 85 and at end-of-study, respectively.

Example 2: Study A2204

The purpose of the study is to evaluate the safety, tolerability, pharmacokinetics (PK) and bone response following a single i.v. dose of Antibody 1 in patients with CKD-5Don hemodialysis and evidence of MBD. The study will also the question of whether the PK profile of Antibody 1 is altered in CKD-5D patients due to frequent hemodialysis or, for example, adherence of Antibody 1 or Antibody 1-sclerostin immune-complexes to the dialysis cartridge membrane.

In addition, this study will generate data on the bone anabolic effects of Antibody 1 in patients with CKD-5D and MBD by analyzing serologic bone biomarkers and its effect on bone formation by Positron Emission Tomography with ¹⁸F-fluoride (¹⁸NaF-PET) imaging. Renal failure produces bone disorders characterized by reduced bone formation and/or impaired mineralization, such as ABD. Bone biopsy with double tetracycline labeling is considered a gold standard for the direct histomorphometric assessment of bone metabolic activity, but it is invasive and complex. Bone turnover markers (BTMs) in serum or urine can provide rapid response in changes in metabolic activity across the whole skeleton, but cannot provide insight into changes that occur at specific sites such as hip or spine. ¹⁸NaF-PET is a non-invasive imaging technique that has been developed to measure site-specific bone formation rates and is well suited for serial studies (M. Frost et.al (2011) J. Bone Miner Res. 26: 1002-11; Messa et al (1993) J. Clin. Endocrinol. Metab. 77:949-55).

This is an exploratory, non-confirmatory, randomized, double-blind, placebo- controlled study in subject with CKD-5D and evidence of MBD as judged by low serum intact PTH levels according to KDIGO guidelines. Approximately ten subjects will be enrolled to receive a single dose of either BPS804 or placebo. For each subject the study consists of a Screening visit, a Baseline visit, followed by a single i.v. dose of 20 mg/kg BPS804 or placebo on Day 1. This single-dose treatment period will be followed by a 12- week follow-up period and study completion evaluations. The first two subjects entering in the study will receive an open-label BPS804 intravenous infusion of 20 mg/kg over approximately two hours. After infusion, the subjects will remain domiciled for 24 hours. A

2-week safety review period will follow, during which time the subjects will be monitored for any adverse effects. PK analysis will be conducted following the first 48 hours blood sampling [including blood samples from pre-dose; 2 hr, 24 hr, 48 hr (pre-dialysis) and 48 hr (post-dialysis) and dialysate samples from 48 hr post-dialysis] to evaluate whether the concentration of BPS804 in the blood is affected by dialysis. If there are no significant safety concerns or PK effects following the 2-week safety review period, the remaining 8 subjects will be dosed with BPS804 20 mg/kg or placebo in a double-blind fashion following a 6:2 ratio (BPS804 : placebo).

The study aims to collect safety, tolerability, and pharmacokinetic/pharmacodynamic (PK/PD) data after a single dose of Antibody 1 administered i.v. to male and female patients with stage 5D CKD-MBD. The study will be randomized, placebo-controlled and double- blind to ensure the robust comparison of adding Antibody 1 to current care of these patients with regard to efficacy and safety assessments. To identify a pharmacodynamic effect of Antibody 1 in this population, serological bone biomarker and bone imaging assessments by ¹⁸NaF-PET have been incorporated into this study to detect any changes in bone metabolism pre- and post-treatment. Similarly, the biologic activity of Antibody 1 as a bone anabolic agent will be assessed using dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT) scans pre- and post-treatment.

The study population will be comprised of male and female CKD-5D patients on stable hemodialysis, with evidence of mineral and bone disorder, and adynamic bone disease as evidence by low iPTH levels as per KDIGO guideline (intact PTH <100 pg/mL) (Moe et al. 2009). The study population represent a population that is at risk of developing low bone mineral density and bone fractures due to alterations in their mineral metabolism caused by the underlying CKD. Ten patients will be randomized. Antibody 1 caused an increase in BMD in preclinical studies and in the clinical study A2101 as measured by DXA at the lumbar spine. Therefore an increase in BMD in stage 5D CKD patients may be more easily detectable due to their underlying osteopenic / osteoporotic state and administration of Antibody 1 might offer some benefit in terms of increasing BMD.

For patients to be eligible for inclusion into this study they must meet all of the following criteria:

•Written informed consent must be obtained before any assessment is performed. •Males and females aged 18 to 80 years of age included, with CKD-5D (GFR < 15 mL/min per 1.73m2) on stable hemodialysis as evidence by monthly Kt/Vurea > 1.20 (obtained from local laboratory) or urea reduction ratio > 60% (obtained from local laboratory) for past 3 consecutive months prior to first dosing, and evidence of Adynamic Bone Disease assessed by serum intact PTH of less than 100 pg/mL.

•Subject must be on maintenance renal replacement therapy (i.e., hemodialysis, hemofiltration or hemodiafiltration) 3 times per week, for > 3 months before screening with a stable dialysis prescription, as defined by no change in material (i.e., dialyzer, filter/ membrane) type and dialysis duration for > 4 weeks before screening and planned to be maintained the same throughout the study duration.

•Having 2 evaluable consecutive vertebral bodies for DXA (no fractures, no sclerosis).

•Serum calcium, P04, PTH, and vitamin D within KDIGO guidelines for >80% of samples over the past 3 months prior to first dosing.

•If subject is currently being treated with calcimimetics, the prescribed dose must be constant for at least 30 days prior to screening and should remain constant during the study duration.

•If subject is currently being treated with vitamin D, the prescribed dose must be constant for at least 30 days prior to screening and should remain constant during the study duration.

•Able to communicate well with the investigator, to understand and comply with the requirements of the study.

•Must have screening body mass index (BMI) between >18.5 and <30 kg/m2 and must weigh at least 50 kg

•Low BMD, defined as a Z-score for the lumbar spine between -1.0 and >- 4.0 as determined by DXA at time of screening.

Deviation from any entry criterion excludes a subject from enrollment into the study.

The 5:2 randomization allows comparison between the Antibody 1 regimen and the placebo group and is considered sufficient for comparison of safety and pharmacodynamic (PD) of the treatment regimen versus placebo. The maximum intended dose in the current study is 20 mg/kg single iv administration, the same as the maximum tested dose in the clinical study A2101, which was well tolerated and no overt safety or organ-specific concerns were noted. Dose levels of 10 and 20 mg/kg provided the maximum expected effect on circulating sclerostin levels in healthy postmenopausal women, with the 20 mg/kg dose providing statistical significant effects on bone formation biomarkers. The 20 mg/kg dose exhibited significant changes from baseline BMD in the A2101 single dose clinical study.

The follow-up period is consistent with and based on information gained from the clinical study A2101 and is expected to cover the extent of any PK PD (i.e., target capture) response as well as allowing assessment of any potential impact from hemodialysis.

Placebo is used as comparator. Placebo patients will be compared informally to patients on active with respect to the safety profile.

Example 3: Fgf23 expression is decreased in Sost deficient female mice

Sost knockout (KO) mice with a targeted disruption of the Sost coding region were licensed from Deltagen, Inc., USA. Briefly, targeted ES cells derived from the 129/OlaHsd mouse substrain were used to generate chimeric mice, which were bred with C57BL/6 mice. Heterozygous Sost KO offspring was backcrossed for four generations to C57BL/6 mice and then interbred to generate homozygous Sost deficient mice, which were maintained on a mixed genetic background. All mice were kept in cages under standard laboratory conditions with constant temperature of 25°C and a 12-12-hour light-dark cycle. Mice were fed on a standard rodent diet (3302, Provimi Kliba SA, Switzerland) with water ad libitum. At 6 months of age, female Sost KO and their corresponding sex-matched wild-type littermate mice were sacrificed and blood and bone samples were collected. Protocols, handling, and care of the mice conformed to the Swiss federal law for animal protection under the control of the Basel-Stadt Cantonal Veterinary Office, Switzerland.

Total RNA was isolated from cortical bone of femoral diaphyses using TRIzol (Invitrogen) and R easy Mini (Qiagen) as previously described (Keller and Kneissel, 2005), followed by reverse -transcription into cDNA using the High Capacity cDNA Reverse Transcription Kit (Applied Biosystems) according to the manufacturer's recommendation. Fg/23 gene expression was analyzed with an ABI Prism 7900HT sequence detection system (Applied Biosystems) using TaqMan® Universal PCR Master Mix, mouse 18S TaqMan® assay reagent for normalization and mouse Fg/23 TaqMan® probe (Mm00445621_ml) according to the manufacturer's instructions (Applied Biosystems).

Serum was separated from whole blood using clot activator centrifugation tubes (Sarstedt). Serum Fgf23 levels were determined by ELISA detecting intact Fgf23 (Kainos) according to the manufacturer's recommendation using 50 μΐ of serum samples.

Fgf23 expression was strongly and significantly decreased by 63% relative to wild- type in 6-month-old Sost deficient female mice (n = 10 Sost KO [SOs/^7"] versus n = 10 wild- type littermate [Sos/⁺], p < 0.01) (Figure 2A). Consistently, Fgf23 serum levels were also significantly reduced by 24% in 6-month-old Sost KO female mice (n = 6 Sost KO [Sosf ^{~ ~}] versus n = 6 wild-type littermate [Sos/⁺], p < 0.05) (Figure 2B).

Claims

WHAT IS CLAIMED IS:

1. A method of treating chronic kidney disease (CKD) with evidence of mineral and bone disorder (MBD), comprising administering to a patient having CKD with evidence of MBD a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof selected from the group consisting of Antibody 1, Antibody 2, Antibody 3, Antibody 4 and Antibody 5.

2. The method of claim 1, wherein the patient has stage 3-5 CKD, preferably stage 5 CKD.

3. The method of claim 2, wherein the patient is on hemodialysis, peritoneal dialysis,

hemofiltration, or hemodiafiltration.

4. The method of claim 3, wherein the patient is on hemodialysis, and wherein the

hemodialysis is high-flux hemodialysis, on-line hemodialysis or both high-flux and online hemodialysis.

5. The method of claim 1, wherein the patient has renal osteodystrophy (ROD).

6. The method of claim 5, wherein the patient has adynamic bone disease (ABD), as

evidenced by bone biopsy and histomorphometric analysis, ¹⁸F -fluoride PET-CT imaging, or serum intact PTH (iPTH) levels of less than 100 pg/ml.

7. The method of claim 1, wherein the anti-sclerostin antibody or antigen-binding fragment thereof is administered to the patient at about 10 to about 40 mg/kg, preferably about 20 mg/kg.

8. The method of claim 1, wherein the patient displays an improvement in lumbar spine bone mineral density (BMD) of at least about 0.5% increase above placebo, as measured by dual-energy x-ray absorptiometry (DXA).

9. The method of claim 1, wherein the patient displays an improvement in hip and lumbar spine bone formation as measured by ¹⁸F -fluoride PET-CT imaging.

10. The method of claim 1, wherein the patient displays an improvement in volumetric BMD as measured by quantitative computed tomography (QCT).

11. An anti-sclerostin antibody or antigen-binding fragment thereof selected from the group consisting of Antibody 1, Antibody 2, Antibody 3, Antibody 4 and Antibody 5 for use in treating CKD with evidence of MBD in a patient in need thereof.

12. Use of an anti-sclerostin antibody or antigen-binding fragment thereof selected from the group consisting of Antibody 1, Antibody 2, Antibody 3, Antibody 4 and Antibody 5 for the manufacture of a medicament for treating CKD with evidence of MBD in a patient in need thereof.

13. The use of claim 11 or 12, wherein the patient has stage 3-5 CKD.

14. The use of claim 13, wherein the patient has stage 5 CKD.

15. The use of claim 14, wherein the patient is on hemodialysis, peritoneal dialysis,

hemofiltration, hemodiafiltration, or intestinal dialysis.

16. The use of claim 15, wherein the patient is on hemodialysis, and wherein the hemodialysis is high-flux hemodialysis, on-line hemodialysis or both high-flux and on-line

hemodialysis.

17. The use of claim 11 or 12, wherein the patient has ROD.

18. The use of claim 17, wherein the patient has ABD, as evidenced by bone biopsy and histomorphometric analysis, ¹⁸F-fluoride PET-CT imaging, or serum intact PTH (iPTH) levels of less than 100 pg/ml.

19. The use of claim 11 or 12, wherein the anti-sclerostin antibody or antigen-binding

fragment thereof is administered to the patient at about 10 to about 40 mg/kg, preferably about 20 mg/kg.

20. The use of claim 11 or 12, wherein the patient displays an improvement in lumbar spine bone mineral density (BMD) of at least about 0.5% increase above placebo, as measured by dual-energy x-ray absorptiometry (DXA).

21. The use of claim 11 or 12, wherein the patient displays an improvement in hip and lumbar spine bone formation as measured by ¹⁸F -fluoride PET-CT imaging.

22. The use of claim 11 or 12, wherein the patient displays an improvement in volumetric BMD as measured by quantitative computed tomography (QCT).

23. A kit for use in treating a patient having CKD with evidence of MBD, comprising: a. a therapeutically effective amount of an anti-sclerostin antibody or antigen-binding fragment thereof selected from the group consisting of Antibody 1, Antibody 2, Antibody 3, Antibody 4 and Antibody 5; b. optionally, means for administering said anti-sclerostin antibody or antigen binding fragment thereof to the patient; c. optionally, at least one additional agent selected from the group consisting of a bisphosphonate (zoledronic acid, alendronate, risedronate), denusomab/Prolia, estrogen, tibolone, progestin, androgen, a PTH or PTH analog, lithium chloride, fluoride, glucocorticosteroids (e.g., prednisone), a sclerostin antagonist, and SERMs (raloxifene, tamoxifen); strontium ranelate and cathepsin K inhibitors. d. instructions for administering said anti-sclerostin antibody or antigen binding fragment thereof to the patient.

24. The method, use or kit of claim any of the above claims, wherein said anti-sclerostin antibody or antigen-binding fragment thereof: a. binds to human sclerostin with a K_D less than 10 nM as determined by surface plasmon resonance or a biosensor system; b. has an IC₅₀ less than 1 μΜ as measured in a cell -based Wnt signaling assay in HEK293 cell lines in the presence of sclerostin; c. has an IC50 less than 1 μΜ as measured in BMP2 -induced mineralization assay in MC3T3 cells in the presence of sclerostin; d. has an IC₅₀ less than 1 μΜ as measured in LRP6/sclerostin ELISA; and/or e. has an IC₅₀ less than 1 μΜ as measured in BMP6 Smadl phosphorylation assay in MC3T3-E1 cell line in the presence of sclerostin.

25. The method, use or kit of any of the above claims, wherein the anti-sclerostin antibody or antigen-binding fragment thereof is selected from the group consisting of: a. an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:4; b. an anti-sclerostin antibody or antigen-binding fragment thereof comprising a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:5; c. an anti-sclerostin antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising the amino acid sequence set forth as SEQ ID NO:4 and a light chain variable region comprising the amino acid sequence set forth as SEQ ID NO:5; and d. an anti-sclerostin antibody or antigen-binding fragment thereof comprising the three Complementarity-Determining Regions (CDRs) of the amino acid sequence set forth as SEQ ID NO:4 and the three CDRs of the amino acid sequence set forth as SEQ ID N0 5.

26. The method, use or kit of claim 25, wherein the three CDRs of the amino acid sequence set forth as SEQ ID NO: 4 are set forth in SEQ ID NO: 6, SEQ ID NO: 7, and SEQ ID NO:8.

27. The method, use or kit of claim 25, wherein the three CDRs of the amino acid sequence set forth as SEQ ID NO: 5 are set forth in SEQ ID NO: 9, SEQ ID NO: 10, and SEQ ID NO: 11.

28. The method, use or kit of any of the above claims, wherein said anti-sclerostin antibody or antigen-binding fragment thereof is an anti-sclerostin antibody.

29. The method, use or kit of claim 28, wherein said anti-sclerostin antibody is a chimeric antibody, a humanized antibody, or a human antibody.

30. The method, use or kit of claim 29, wherein said anti-sclerostin antibody is a monoclonal anti-sclerostin antibody or a human recombinant anti-sclerostin antibody.

31. The method, use or kit of claim 30, wherein said anti-sclerostin antibody is of the IgGi, IgG₂ or IgG₄ isotype.

32. The method, use or kit of any one of claims 1-27, wherein said anti-sclerostin antibody or antigen-binding fragment thereof is an antigen-binding fragment of an antibody.

33. The method, use or kit of claim 32, wherein said antigen-binding fragment comprises an F(ab')2, Fab, Fab', Fv, Fc or Fd fragment.

34. A method of reducing serum phosphate levels in a patient in need thereof, comprising administering a therapeutically effective amount of Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5 to said patient.

35. The method according to claim 34, wherein the patient has vascular calcification.

36. A method of increasing serum PTH levels in a patient in need thereof, comprising administering a therapeutically effective amount of Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5 to said patient.

37. The method of claim 36, wherein the patient has Adynamic Bone Disease (ABD).

38. A method of reducing FGF23 levels in a patient in need thereof, comprising administering a therapeutically effective amount of Antibody 1, Antibody 2, Antibody 3, Antibody 4 or Antibody 5 to said patient.

39. The method of claim 38, wherein the patient has left ventricular hypertrophy.