Akebia Therapeutics (AKBA) Q3 2026 earnings review
Akebia adds Vafseo patients slowly, and customer destocking cuts sales
Akebia Therapeutics, a kidney disease drug maker, saw revenue from its new anemia pill Vafseo drop while generic rivals cut into its older medicine Auryxia. Total revenue fell 37% from a year ago to $37 million, swinging the company to a $14 million net loss. Chief executive John P. Butler pointed to rising patient counts on Vafseo, but quarterly sales of the drug fell 31% from last quarter because its largest customer reduced inventory ahead of a Medicare payment change.
| Total revenue | $36.9M -37% from a year ago |
|---|---|
| Vafseo net product revenue | $14.8M -31% from last quarter |
| Active patients on Vafseo | 11,500 +8.1% from last quarter |
| Auryxia 2026 revenue outlook | Unchanged expected to decrease vs 2025 |
⚖️ Verdict: 🔴 Bearish
The story got worse because Vafseo's underlying patient growth slowed sharply just before its price is set to fall in January 2027. Active patients rose 8% from last quarter after climbing 41% in the second quarter, and the company still has not refinanced the debt that underpins its two-year cash plan. On the positive side, two clinical trials confirmed that giving Vafseo three times a week is safe and effective, matching how dialysis clinics treat patients.
The question now is whether Vafseo can add enough patients in 2027 to make up for lower prices once temporary Medicare payments end in December. Either the new hospitalization data convinces large dialysis chains to switch patients in bulk, or lower 2027 pricing shrinks Vafseo revenue alongside Auryxia. First-quarter 2027 Vafseo sales and patient counts will tell.
🐂 Bull Case
Two Clinical Trials Back Three-Times-Weekly Vafseo Dosing
Vafseo is Akebia's daily pill for anemia in adults on dialysis, a blood-cleaning treatment for kidney failure. Most dialysis clinics prefer to give medicine three times a week during clinic visits, and chief executive John P. Butler wants Vafseo to replace standard erythropoiesis-stimulating agents (ESA), which are injected anemia drugs.
This quarter delivered two clinical readouts testing that three-times-weekly schedule. In October, U.S. Renal Care presented the VOICE trial, showing better safety outcomes than standard injections because of "a significant reduction in hospitalization rate". In November, the kidney drug maker reported that its VOCAL trial met its main goal of matching standard injections in maintaining red blood cell protein levels.
The VOCAL readout resolves a disclosure gap after the study went unmentioned last quarter. Together, the two trials give clinics clinical proof to use the three-times-weekly schedule as Medicare payment rules change in 2027.
What to watch: quarterly Vafseo patient additions in early 2027. Faster patient additions will show whether the hospitalization data convinces large dialysis chains to switch patients.
First Patient Dosed in Rare Kidney Disease Trial
Akebia is building a pipeline of experimental medicines for rare kidney diseases to drive future value alongside its commercial dialysis drugs. The lead candidate in this effort is ebribafusp alfa, a drug designed to block part of the immune system that damages kidney filters.
In September, the Massachusetts biotech dosed the first patient in a mid-stage trial of ebribafusp alfa. The open-label study will enroll up to 30 patients across three rare kidney conditions, and the company also presented posters on praliciguat, its second mid-stage kidney candidate, at a medical meeting in October. Research and development spending rose 8.3% from a year ago to $16.2 million to fund these trials.
Dosing the first patient on schedule keeps the pipeline moving toward its first clinical readout in 2027. However, rising trial costs add to the company's cash burn while its older product revenues shrink.
What to watch: initial clinical data from the ebribafusp alfa trial in 2027. Early signs of kidney benefit in the 30-patient study will test whether the pipeline can support the business.
🐻 Bear Case
Vafseo Patient Growth Slowed as Inventory Cut Sales
"Our strategic commercial priority remains making Vafseo standard of care for the treatment of anemia for patients on dialysis, and we are focused on continuing to increase the number of patients on therapy," chief executive John P. Butler said. Butler expects clinic access to widen in 2027 "when we believe Vafseo access will expand beyond the Transitional Drug Add-on Payment Adjustment (TDAPA)-only patients to nearly all clinically eligible patients", referring to the temporary Medicare payment program that ends in December 2026.
Instead of building momentum into that transition, Vafseo growth slowed down in the third quarter. The drug brought in $14.8 million, down 30.5% from last quarter because of "an inventory reduction at our largest customer" as the Medicare payment deadline nears.
- Active patients on Vafseo: about 11,500, up 8.1% from last quarter after rising 41% in the second quarter
- New patients added: about 860 by our math, down from more than 3,000 added last quarter
- Total prescribers: about 1,300, up 8.3% from last quarter after rising 17% in the second quarter
- Revenue per active patient: $1,287 by our math, down from $2,029 in the second quarter
Customer destocking explains the revenue drop, but it does not explain why net patient additions slowed to an 8.1% gain. When Vafseo enters the standard Medicare dialysis bundle in January 2027, its price will drop to match cheaper competing drugs, so the company needs a much larger patient base just to hold revenue steady.
What to watch: fourth-quarter Vafseo active patients and net product revenue. Another quarter of single-digit patient growth would leave the drug with too little volume ahead of the January 2027 price reset.
Generic Rivals Halved Auryxia Sales and Widened Losses
Auryxia, Akebia's older pill that controls phosphorus and iron levels in kidney patients, has funded the business during the Vafseo rollout. Since losing patent protection in 2025, Auryxia has faced "generic competition and pricing pressure" that is shrinking its sales.
Auryxia net product revenue fell 52.9% from a year ago and 21.6% from last quarter to $20.0 million. Because Vafseo also declined sequentially, total revenue dropped 37.2% from a year ago to $36.9 million, and operating profit swung from a $4.4 million gain a year ago to an $11.5 million loss.
The operating margin fell 38.6 percentage points from a year ago to negative 31.1% by our math. Research and development rose 18.4 percentage points of revenue to 43.9%, and selling, general and administrative expenses rose 14.3 percentage points of revenue to 63.8% because sales shrank faster than overhead.
What to watch: fourth-quarter Auryxia net product revenue. A drop below $15 million would show generic substitution is still taking roughly $5 million of high-margin sales each quarter.
Two-Year Cash Plan Still Depends on Debt Refinancing
Akebia ended September with $159.3 million in cash, up $3.7 million from June. Management stated that existing cash and expected revenues, "along with our plan to refinance our senior secured term loan facility, will enable us to fund our current operating plan for at least two years". That loan begins requiring principal repayments in January 2027.
The company has not yet completed that refinancing, and its balance sheet cushion tightened despite the slightly higher cash balance. Working capital, which measures short-term assets minus short-term bills due within a year, fell 14.9% from last quarter to $58.4 million, while quarterly net losses widened to $14.4 million.
What to watch: a completed debt refinancing announcement before January 1, 2027. Entering 2027 without a new loan agreement would force Akebia to pay down debt principal just as Vafseo prices reset lower.
Risks this quarter didn't answer
Several standing commercial and accounting risks received no new numbers in the third-quarter earnings release.
- Post-2026 Vafseo pricing: management gave no price or 2027 revenue range as the temporary Medicare payment period ends on December 31, 2026.
- DaVita clinic adoption: the release did not mention prescribing trends at DaVita after its clinic protocol launched in June.
- Pre-launch inventory and write-downs: cost of goods sold still benefited from Vafseo pills expensed before approval, and the remaining balance and any write-downs await the quarterly Form 10-Q filing.
👓 Other Themes
Staff Cuts Lowered Quarterly Overhead Expenses
In June, Akebia reorganized its sales team to focus on large dialysis groups and cut its workforce. In the third quarter, selling, general and administrative expenses fell 19.1% from a year ago and 16.5% from last quarter to $23.5 million on "lower marketing costs and decreased headcount-related costs". The drug maker also booked a $1.3 million restructuring charge during the quarter, following a $1.9 million charge in the second quarter.
💲 Other KPIs
Working capital — short-term assets minus short-term liabilities — shrank for a third straight quarter. It fell 14.9% from June and 35.1% from $90.0 million at the end of 2025, even though cash rose slightly to $159.3 million, showing that short-term obligations grew or other current assets declined.
The weighted-average diluted share count rose 2.7% from 269.6 million in the second quarter and 0.9% from a year ago. Basic shares rose 4.6% from a year ago as the kidney drug maker continued issuing stock, increasing the share count by more than 7.2 million shares since the second quarter.
Revenue from licensing and partner agreements rose 5.0% from $2.0 million a year ago, down slightly from $2.4 million in the second quarter. This stream remains a small, steady contributor alongside product sales.
🔮 Guidance
Unchanged. Akebia still expects full-year Auryxia sales to fall from 2025 levels because of generic competition and lower prices. Through the first nine months of 2026, Auryxia sales totaled $81.7 million, down 38.8% from $133.5 million in the first nine months of 2025 by our math.
Unchanged. Management still expects its $159.3 million in cash and future product revenues to fund operations for at least two years. As in the second quarter, that two-year plan requires the company to refinance its senior secured term loan facility.
❓ Key Questions
Why did Vafseo patient additions slow to 8%?
Active patients rose 8.1% to 11,500 after growing 41% in the second quarter and 60% in the first quarter. Did clinic onboarding slow down ahead of the January 2027 payment transition, or did more patients stop taking the drug?
How many dollars did customer inventory cuts remove?
Vafseo revenue fell $6.5 million from last quarter even though the patient count grew by 8.1%. Last fourth quarter, Akebia quantified a $4.5 million to $5.0 million inventory reduction; how large was the third-quarter cut, and is destocking finished?
When will Akebia refinance its senior secured term loan?
Principal payments on the $50.6 million term loan begin on January 1, 2027, less than two months away, and the two-year cash outlook depends on refinancing it. What terms are lenders offering as total revenue declines?
What will Vafseo cost after Medicare payment rules change?
When temporary Medicare add-on payments end on December 31, 2026, Vafseo moves into the standard dialysis payment bundle alongside cheaper drugs. What net price per patient does the 2027 operating plan assume?