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Imipridone (ONC201; DRD2/ClpP)

Dordaviprone

Modeyso · DOR

Imipridone (ONC201; DRD2/ClpP) · approved 2025 · 2 references

The first imipridone (ONC201) for H3 K27M diffuse glioma — a drug whose safety story centers on the QT interval, not the kidney, which it largely leaves alone.

Signature injury
Prerenal / Hemodynamic AKI
Severity
Mild
Reversibility
Reversible
Onset
No drug-specific renal onset. QT effects are the on-treatment finding to monitor; any prerenal creatinine change would follow an intercurrent volume-depleting event.

Signature kidney injury & incidence

Prerenal / Hemodynamic AKI.

Dordaviprone carries no meaningful renal signal and no discrete published incidence of drug-related acute kidney injury. Its clinically important safety consideration is cardiac — QT-interval prolongation — rather than renal, and the intermittent oral schedule is generally well tolerated. Across its glioma program (Arrillaga-Romany, Neuro Oncol 2024, describes the phase 3 ACTION design and prior recurrent-disease efficacy), the toxicity profile is dominated by fatigue and QT effects, not nephrotoxicity. Any renal contribution would be indirect (prerenal physiology from intercurrent illness) rather than an intrinsic tubular or glomerular toxicity.

Source: No meaningful renal signal; QT prolongation (not nephrotoxicity) is the safety focus (ACTION program, Arrillaga-Romany 2024)

Reported injury signatures: Prerenal / Hemodynamic AKI.

Mechanism of kidney injury

Dordaviprone has no established direct renal toxicity. Its targets (DRD2 and mitochondrial ClpP) are not a nephron-specific injury pathway, and it is not primarily renally cleared, so the kidney is neither a target nor the elimination route. The only realistic routes to a kidney problem are indirect and non-specific: prerenal azotemia from volume depletion during an intercurrent illness, or an electrolyte disturbance that, combined with the drug's QT effect, raises arrhythmia risk (making potassium and magnesium worth keeping normal for cardiac rather than renal reasons). There is no described tubular, interstitial, or glomerular lesion attributable to the drug.

Clinical presentation

No characteristic renal presentation; renal function is expected to remain stable. The safety picture to watch is a prolonged QT (and its interaction with hypokalemia/hypomagnesemia), not a rising creatinine. A creatinine change on therapy is usually explained by an intercurrent prerenal insult rather than by the drug.

Management

No dordaviprone-specific renal management is required. Correct and maintain potassium and magnesium (for QT safety), restore volume for any prerenal creatinine rise, and address the precipitant. Investigate a progressive creatinine rise, proteinuria, or an active sediment as a separate renal process. There is no role for dialysis or drug-specific renal rescue for this agent.

Risk factors

  • Intercurrent volume depletion (vomiting, diarrhea, poor intake) causing prerenal physiology
  • Electrolyte disturbances (hypokalemia, hypomagnesemia) — chiefly a QT/arrhythmia concern
  • Concurrent QT-prolonging drugs
  • Baseline CKD (lowers reserve for any intercurrent insult)

Prevention

  • Keep potassium and magnesium normal — primarily to protect the QT interval, secondarily for renal-electrolyte health
  • Maintain hydration during intercurrent GI illness
  • Review co-medications for additive QT prolongation
  • Routine chemistry and ECG monitoring per the drug's cardiac guidance

Renal dose adjustment

No renal-impairment dose adjustment is established; dordaviprone is an orally administered small molecule given on an intermittent schedule and is not primarily renally cleared. Dose interruption/modification is driven by tolerability and by QT/cardiac considerations rather than by GFR.

Dialyzability & ESKD dosing

Not characterized as dialyzable and not clinically relevant: dordaviprone is not primarily renally eliminated, and there is no renal-clearance or drug-removal scenario in which dialysis is relevant. Renal replacement therapy would only ever address an unrelated AKI.

Differential diagnosis

Any renal abnormality in a patient on dordaviprone should be attributed to a cause other than the drug: prerenal volume depletion, a concurrent nephrotoxin, contrast, obstruction, or disease. The drug's own safety signal to track is the QT interval, amplified by hypokalemia/hypomagnesemia — an electrolyte-and-cardiac concern, not a tubular-injury one. A true renal lesion warrants an independent workup.

Monitoring

  • ECG/QT interval per the drug's cardiac guidance (the key safety monitor)
  • Serum potassium and magnesium (to protect the QT, and for general electrolyte health)
  • Routine serum creatinine as part of standard care (no drug-specific renal surveillance)
  • Volume status during intercurrent GI illness

Key trials & series

  • ACTION (Arrillaga-Romany, Neuro Oncol 2024) — randomized phase 3 design of dordaviprone (ONC201) in newly diagnosed H3 K27M-mutant diffuse glioma after radiotherapy, following demonstrated efficacy in recurrent disease; the pivotal program whose toxicity profile centers on tolerability and QT rather than renal injury.
  • Emerging targeted therapies in pediatric brain tumors (Terashima, No Shinkei Geka 2025) — review situating dordaviprone's accelerated approval for H3 K27M diffuse midline glioma within the precision-oncology landscape.

Clinical pearls

  • Watch the heart, not the kidney: dordaviprone's safety signal is QT prolongation, and the nephron is largely a bystander.
  • Keep potassium and magnesium normal mainly to protect the QT interval — a cardiac motive for an electrolyte habit.
  • A creatinine rise on dordaviprone is almost always intercurrent volume depletion or another cause — investigate accordingly.
  • Its dose is modified for tolerability and QT, not for GFR.
  • The 'imipridone' class (ClpP agonism) does not carry a known nephron-specific toxicity.

Anticancer mechanism

Oral small molecule, the first-in-class 'imipridone,' that acts as a selective antagonist of dopamine receptor D2/D3 (DRD2) and, more importantly for its antitumor effect, as an agonist of the mitochondrial protease ClpP; hyperactivating ClpP degrades respiratory-chain subunits, disrupting oxidative phosphorylation and triggering an integrated stress response and apoptosis, with particular activity in H3 K27M-mutant diffuse gliomas. It is given orally on an intermittent (weekly or twice-weekly) schedule.

Guidelines & consensus

  • ADQI (2026) — The nephrotoxic effects of anti-cancer therapies: consensus report of the 34th Acute Disease Quality Initiative workgroupProvides expert-based statements (modified Delphi) on preventing and managing cisplatin/platinum-associated AKI, including isotonic IV hydration, attention to volume status and concomitant nephrotoxins, and incorporates evidence that IV magnesium supplementation may reduce cisplatin-associated AKI; emphasizes risk stratification and standardized AKI definitions.Nat Rev Nephrol · PMID 41361704
  • SIRM (2022) — SIRM-SIN-AIOM: appropriateness criteria for evaluation and prevention of renal damage in the patient undergoing contrast medium examinations-consensus statements from Italian College of Radiology (SIRM), Italian College of Nephrology (SIN) and Italian Association of Medical Oncology (AIOM)Recommends eGFR-based renal risk assessment and pre/post-contrast isotonic saline or sodium bicarbonate hydration; advises maintaining a 5-7 day interval between iodinated contrast administration and cisplatin in cancer patients to reduce additive nephrotoxicity.Radiol Med · PMID 35303246
  • KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancerIdentifies platinum compounds (especially cisplatin) as leading cytotoxic causes of acute tubular injury, AKI, and electrolyte/magnesium wasting; calls for interdisciplinary onco-nephrology care, accurate GFR estimation, and individualized drug dosing in patients with reduced kidney function.Kidney Int · PMID 33126977
  • KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantationAddresses chemotherapy-associated AKI/CKD in hematologic cancer, GFR estimation and chemotherapy dosing in patients with reduced kidney function, and management priorities and research gaps for onco-nephrology care.Kidney Int · PMID 33276867
  • ADDIKD (2025) — Integrating International Consensus Guidelines for Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) into everyday practiceProvides GRADE-based, drug-specific dose-adjustment recommendations for anticancer agents in kidney dysfunction (illustrated for methotrexate, cisplatin, carboplatin and nivolumab); the recommendations build on Part 1's standardised CKD-EPI eGFR assessment rather than Cockcroft-Gault creatinine clearance.EClinicalMedicine · PMID 40290844
  • ADDIKD (2025) — Aligning kidney function assessment in patients with cancer to global practices in internal medicineThree consensus recommendations: assess kidney function by GFR (measured GFR or CKD-EPI eGFR), classify it using KDIGO categories, and use this uniform approach to dose anticancer drugs — moving cancer medicine away from Cockcroft-Gault estimated creatinine clearance.EClinicalMedicine · PMID 40290845
  • ADDIKD (2025) — A methodology for determining dosing recommendations for anticancer drugs in patients with reduced kidney functionEstablishes that, where RCT evidence is lacking, anticancer drug dosing recommendations in kidney dysfunction should be derived by critically appraising observational literature via GRADE combined with structured international multidisciplinary consensus voting.EClinicalMedicine · PMID 40290846
  • KDIGO (2013) — Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)Defines/stages AKI by serum creatinine and urine output; emphasizes avoiding nephrotoxins, maintaining euvolemia/perfusion, dose-adjusting drugs to kidney function, and monitoring high-risk patients — the framework applied to nephrotoxic anti-cancer agents.Crit Care · PMID 23394211
  • KDIGO (2021) — Executive summary of the KDIGO 2021 Guideline for the Management of Glomerular DiseasesProvides the staging/treatment framework for drug-associated glomerular lesions (e.g., bisphosphonate- and interferon-related collapsing FSGS, VEGF-inhibitor podocytopathy/proteinuria), including immunosuppression and supportive RAAS-blockade strategies.Kidney Int · PMID 34556300
  • KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated VasculitisUpdates immunosuppressive induction (rituximab/cyclophosphamide), incorporates avacopan and lower-dose or glucocorticoid-sparing regimens — the management framework for drug- and checkpoint-inhibitor-associated ANCA/pauci-immune glomerulonephritis.Kidney Int · PMID 38388147
  • KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus NephritisUpdates first-line lupus nephritis therapy to combination immunosuppression with the addition of belimumab or a calcineurin inhibitor (voclosporin) — informs management of immune-complex/lupus-like glomerulonephritis encountered with immunotherapy.Kidney Int · PMID 38182299
  • KDIGO (2025) — Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV)Encourages liberal kidney biopsy and stricter proteinuria control (<0.5 g/d, ideally <0.3 g/d) with RAAS blockers, SGLT2 inhibitors, and targeted-release budesonide — the framework for IgA-dominant glomerular lesions, including those triggered by immune-modulating cancer therapy.Kidney Int · PMID 40975525

References

2 peer-reviewed references. Citation metadata via PubMed / NLM.

  1. 1.ACTION: a randomized phase 3 study of ONC201 (dordaviprone) in patients with newly diagnosed H3 K27M-mutant diffuse glioma.Arrillaga-Romany I, Lassman A, McGovern SL, et al. · Neuro Oncol · 2024 · PMID 38445964
  2. 2.[Emerging Targeted Therapies and Ongoing Clinical Trials in Pediatric Brain Tumors].Terashima K. · No Shinkei Geka · 2025 · PMID 41362032
Educational monograph from NephTox (nephtox.com). Not medical advice — verify against current guidelines before any clinical decision.