A Phase I/II Trial to Evaluate the Safety and Tolerability of Ides® (IgG Endopeptidase) to Eliminate Donor Specific HLA Antibodies (DSAs) and Prevent Antibody-Mediated Rejection Post-Transplant in Highly-HLA Sensitized Patients.
Phase: PHASE1
Conditions: Renal Disease
Sponsor: Cedars-Sinai Medical Center

Page 1 of 38 
 
      
 
 
Stanley  
Jordan, 
M.D 
August 24 
2016 
A Phase I/II Trial to Evaluate the Safety and Tolerability 
of Ides® (IgG endopeptidase) to Eliminate Donor 
Specific HLA Antibodies (DSAs) and Prevent Antibody-
Mediated Rejection Post-Transplant in Highly-HLA 
Sensitized Patients. 
IgG 
endopeptidase 

PROTOCOL 
STUDY TITLE: 
A Phase I/II Trial to Evaluate the Safety and Tolerability of IdeS® (IgG endopeptidase) to 
Eliminate Donor Specific HLA Antibodies (DSAs) and Prevent Antibody-Mediated 
Rejection Post-Transplant in Highly-HLA Sensitized Patients. 
Study Drug 
IdeS® (IgG endopeptidase) 
Support Provided By 
Hansa Medical AB 
Lund, Sweden 
hansamedical.com 
NCT: 02426684 
FDA IND: 124, 301 
Sponsor Investigator 
Name:  Stanley C. Jordan, M.D. 
Institution/Organization: Cedars-Sinai Medical Center 
Address: 8900 Beverly Blvd.  
L.A., CA. 90048
Phone: 310-423-8282 
Fax: 310-423-8208 
Email: sjordan@cshs.org 
Co-Investigator(s) 
Ashley Vo, Pharm.D. 
Director, Transplant Immunotherapy Program 
Institution/Organization: Cedars-Sinai Medical Center 
Address: 8900 Beverly Blvd. 
L.A., CA. 90048
Phone: 310-423-2641 
Coordinating Institution 
Cedars-Sinai Medical Center 
8700 Beverly Blvd. 
L.A., CA. 90048
Research Coordinator 
Jua Choi, Pharm.D. 
Comprehensive Transplant Center 
Cedars-Sinai Medical Center 
8900 Beverly Blvd. L.A., CA.90048 
Version 5.0 (August 24, 2016) 
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1.1. 
IdeS®: An Important New Therapeutic Option for Prevention & 
Treatment of ABMR 
 
IdeS® is an IgG-degrading enzyme of S.pyogenes that cleaves all four human 
subclasses of IgG with strict specificity. IgG degrading activity is a common strategy 
employed by pathogenic bacteria. IdeS hydrolyzes human IgG in positions 236 and 237 
of the lower hinge region of IgG heavy chains. This activity is important since the lower 
hinge region of IgG is critical for interaction with Fc receptors and complement binding.  
Thus the proteolytic activity on IgG molecules at this site prevents IgG mediated 
antibody-dependent cellular cytotoxicity and complement mediated injury to the S. 
pyogenes.  
 
1.2. 
Therapeutic Use of IdeS® for Prevention of Antibody- Mediated 
Injury 
 
As mentioned above, alloantibodies are a major deterrent to access to and success of 
life-saving organ transplants. Despite advancements in desensitization, designing 
efficient and effective means of removal of pathogenic HLA antibodies remains a 
significant medical challenge.  Preliminary data suggests that IdeS® exhibits fast and 
efficient enzymatic digestion of pathogenic antibodies in animal models of autoimmunity 
and on human autoantibodies23, 26. Data from patients with autoimmune neuromyelitis 
optica (NMO) shows that the complement activating and ADCC activity of the 
autoantibody, anti-aquaporin-4, is completely inhibited in vitro by IdeS® treatment.  In 
addition, in vitro treatment of DSA positive serum from highly-HLA sensitized patients 
awaiting transplantation show complete inhibition of DSA activity in the solid phase 
luminex assay (see example in figure 1). The collective data from 12 highly sensitized 
patients demonstrated that IdeS treatment significantly reduced the reactivity in all tested 
patient sera to individual MHC class I and II antigens, as well as the reactivity in 
complement dependent cytotoxicity tests. 
 
 
 
Figure 1 
 
 

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Figure 1. Efficacy of IdeS on anti-HLA IgG in serum from a sensitized patient. Graph shows the 
MFI (Raw) against individual antigens for (upper graph) MHC class-I (A, B and C) and (lower 
graph) MHC class-II (DP, DQ and DR) after mock (blue) and IdeS (red) treatment. MFI: Mean 
fluorescent intensity. 
 
1.3. 
Study Hypothesis 
 
Since alloantibodies are the major mechanism by which allografts are lost and are also 
exclusionary for transplantation of highly-HLA sensitized patients and that current 
approaches to desensitization and treatment of ABMR are not sufficient to completely 
overcome these barriers, an unmet medical need exist to improve the access to and 
success of renal allografts in sensitized patients. To this end, we hypothesize that the 
use of IdeS® pre-transplant in HS patients will represent a more robust and complete 
technique to eliminate DSA from the sera of HS patients. A single dose administration of 
IdeS® in the pre-operative period to HS patients with positive DSAs and flow cytometry 
crossmatches will durably eliminate circulating DSAs, allow transplantation to occur 
without ABMR and, in conjunction with standard desensitization therapy, result in a 
durable suppression of DSA levels thus eliminating the risk for ABMR.  
 
1.4. 
Rationale for Study 
 
Antibody to HLA antigens has a strong impact on mediation of allograft injury and loss. 
As depicted in Figure 2 below, pre-formed or de novo DSAs activate complement, 
induce endothelial cell proliferation antigens and mediate ADCC resulting in a 
progression of allograft dysfunction  and loss. More than 5000 renal allografts are lost 
each year in the U.S., approximately 75-80% to antibody mediated injury13.  Thus, 
understanding the pathophysiology of ABMR and B-cell activation are critical to 
improving the longevity of existing allografts and development of successful strategies 
for desensitization to prevent ABMR.  
 
Figure 2 
 

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Figure 2 shows the time course of DSAs , their impact on allograft histology and the 
eventual progrssion to allograft failure, leaving the recipient highly HLA sensitized. It is 
important to point out the multi-faceted ability of DSAs to mediate allograft injury. Many 
of the pathologic features were once thought to be consequencs of CNI toxicity leading 
to reduced dosing of these critical medications which further accelerated allograft loss. 
Emerging knowledge in this area is critical for development of newer techiniqes for 
suppression of DSA responses. 
 
 
 
 
 
 
 
 

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Figure 3A 
 
 
 
 
Figure 3B 
 
 
 
Figure 3A & 3B: Figure 3A shows the impact of DSAs on long term allograft survival in 
patients transplanted in France (Loupy et al, NEJM, 2013)14. These investigators 
showed that DSAs have a negative impact on long-term graft survival, but when 
segregated by ability to activate complement (C1q+ DSAs), the impact was significantly 
magnified. In fact, those who developed C1q+ DSAs post-transplant has a 12 fold 
greater risk for allograft loss than C1q- DSA patients. Figure 3B shows the mechanisms 
of alloantibody injury to grafts which include complement activation endothelial injury 
through direct actions of alloantibody on ENDATs and ADCC as well as induction of 
accellerated atherosclerosis in allografts13. 
 
Clearly, the most important way to approach antibody mediated allograft injury is through 
the development of antibody-targeted therapies. This would address all pathogenic 
mechansism associated with alloantibody and allow grafts to contine functioning for 
much longer periods of time. This would improve the length and quality of life of allograft 
recipients and reduce costs to the health care system. 
 
Figure 4A & 4B below show data from our center on the long-term outcomes in patients 
who experienced ABMR after desensitization v. those who did not.  
 
 
 
 
 

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Figure 4A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 4B 
 

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Figure 4A & 4B. We retrospectively reviewed the outcomes of 226 
patients who 
underwent desensitization with IVIG + Rituximab +/- PLEX at Cedars-Sinai Medical 
Center. Patients were divided into two groups. Group 1 had no ABMR(80%) while Group 
2 experienced ABMR(20%). As can be seen in Figure 3A, the long-term outcomes in HS 
patients who are ABMR+ are significantly worse than those who were ABMR-.  In fact, 
data for the 5 year outcomes of Group 1 are similar to non-sensitized patients in the 
UNOS data base.  This suggest prevention of ABMR is critical for an excellent long-term 
outcome of allografts. Assessment of factors associated with risk for ABMR showed that 
re-transplantation, female gender, ESRD caused by glomerulonephritis and presence of 
stronger class I and class II DSAs at time of transplant were most important. (Table 1 
below). Figure 3B shows the difficulty in treating ABMR after transplant in HS Patients. 
Patients were treated with IVIG + rituximab or IVIG + rituximab + PLEX. Those treated 
with IVIG + rituximab did better, but this likely  reflects a selection bias as more severe 
cases were treated with PLEX.  Clearly, the most important thing we can accomplish is 
to develop new strategies to prevent ABMR alltogether to allow the long term benefits of 
transplantation to be manifest in these patients.  
 
Table 1  
 
 

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2. Experience with IdeS® in Humans 
 
In January 2014, Hansa Medical, Lund, Sweden announced the successful completion 
of a Phase I study of IdeS® use in humans. The phase I study was performed between 
March 2013 and January 2014 and included 29 healthy subjects. The study was a 
double blind, placebo-controlled, randomized study who received single ascending 
intravenous doses of IdeS® or placebo. Five groups were dosed with the highest dose 
group receiving IdeS doses of 0.24 mg/kg BW (table 2). Study objectives were to 
evaluate safety, tolerability, pharmacokinetics and IgG-cleaving efficacy of the drug 
candidate IdeS®. Details of the study are presented below. 
 
Table 2. Dose groups and number of subjects dosed in clinical study 11-HMedIdeS-01 
Dose group 
Dose 
No of healthy subjects 
IdeS 
Placebo 
1 
0.010 mg/kg BW 
4 
2 
2 
0.010 mg/kg BW 
4 
2 
3 
0.040 mg/kg BW 
4 
2 
4 
0.12 mg/kg BW 
4 
1 
5 
0.24 mg/kg BW 
4 
2 
 
2.1 IdeS® Treatment of Highly-HLA Sensitized Patient with 
Incompatible Transplantation 
One patient in the ongoing phase II study in Uppsala, Sweden has been transplanted 
with a graft from a deceased donor. Patient received two doses of 0.12 mg/kg BW IdeS 
11 and 12 August (20 hours between doses). Patient was offered a graft 14 August. 
Cytotoxic and  FACS crossmatch tests were positive with historic serum, i.e. patient had 
DSA. After two doses of IdeS, both crossmatch tests were negative and the patient was 
transplanted. The effects of IdeS® on DSA levels as detected by luminex are shown in 
Figure 5A below. As can be seen,  all DSAs were reduced to normal range after IdeS® 
therapy. The patient’s course post-transplant is shown in Figure 5B below. Briefly, the 
patient did well post-transplant without infections or rejection episodes. The patient 
returned to work on 10/30/14.  
 
 
 

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Figure 5A 
 
Figure 5A. Graph shows the MFI (Raw) against individual antigens for (upper graph) MHC class-I 
(A, B and C) and (lower graph) MHC class-II (DP, DQ and DR) after mock (blue) and IdeS (red) 
treatment. MFI: Mean fluorescent intensity. 
 
Figure 5B 
 
Figure 5B. Graph shows the course of serum Cr post-transplant. The patient did well without 
rejection or proteinuria and has returned to work today 10/30/14.  
 

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2.2 Safety 
 
2.2.1 Adverse Events 
 
A total of 77 AEs were observed in 24 (82.8%) of the subjects and 39 related AEs were 
observed in 14 (48.3%) of the subjects. In the 0.01 mg/kg dose group there were 24 AEs 
(12 related) in seven of the eight subjects, in the 0.04 mg/kg dose group there were 11 
AEs (6 related) in the four subjects and in the 0.12 mg/kg dose group there were 7 AEs 
(2 related) in three of the four subjects. One subject who experienced a probable 
infusion reaction reported 12 of these AEs. In the Placebo group 14 AEs (7 related) was 
observed in six of the nine subjects. None of the AEs were reported as serious, met any 
dose limiting toxicity criteria or lead to withdrawal of study drug. The most commonly 
reported AE was nasopharyngitis, reported for 50 % (10 out of 20) of the subjects on 
IdeS and for 67% (6 out of 9) of the subjects on placebo. Headache was reported at nine 
occasions by seven subjects, all on IdeS. Seven incidences of fatigue were reported by 
six subjects, five on IdeS and one on placebo. 
 
One subject in the highest dose group experienced a possible infusion reaction 2 
minutes before completion of the infusion. Symptoms were sinus tachycardia, 
pharyngeal oedema, chest discomfort, nasal congestion and flushing. The subject was 
given 2 mL tavegyl (antihistamine)1 mg/mL i.v. and 2 mL betapred (glucocorticoid) 4 
mg/mL i.v. and symptoms resolved within 15 minutes. The IdeS infusion was not 
interrupted and the subject received a full dose. A similar reaction was experienced in 
one subject dosed with placebo. This subject had three episodes of tacycardia in 
connection with dosing and he also had elevated IL-6 levels 6 hours after dosing.  
 
2.2.2 Infections 
 
Since IdeS degrades IgG antibodies there was an initial concern that study subjects 
would have an increased risk of infection. Subjects were screened for inherited 
immunoglobulin disorders, e.g. IgA deficit, before inclusion in the study. Furthermore, 
concerns were raised that study subjects could be carriers of subclinical bacterial agents 
(for example pneumococci) with an increased risk of infection due to reduction of plasma 
IgG. Therefore, subjects received antibiotic prophylaxis (Spektramox 
(amoxicillin/clavulanate) tablets (1x1, 500 mg/125 mg) until serum IgG levels had 
returned to >4.5 g/L. All study subjects compiled to the antibiotic treatment and there 
were no signs of an increasing rate of infections within the study group. 
 
2.2.3 Pharmacokinetics (PK) 
 
IdeS concentrations in serum were detected by a qualified but not validated LC-MS/MS 
method based on four peptides derived from IdeS. The analysis was performed at Lund 
University and serum concentration versus time data was analysed by non-
compartmental analysis (NCA). The pharmacokinetic parameters were calculated up to 
24 hours post dosing, as the remaining concentrations were around or below the 
estimated quantitative range of the method and thus had a high degree of uncertainty. 
 
None of the analysed peptides could be detected in the pre-dose samples or in samples 
from the nine placebo subjects. However, IdeS could be detected in samples from the 20 

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subjects given IdeS, thereby confirming dosing. The IdeS concentration increased with 
dose in the dose interval given, 0.01-0.24 mg/kg IdeS and the increase in the serum 
concentration one minute before end of infusion was dose proportional (figure 6). 
 
Figure 6 
 
Figure 6. Comparison of serum IdeS concentration one minute before end 
of infusion versus dose levels of IdeS (0.01, 0.04, 0.12, and 0.24 mg/kg) 
(logarithmic scale: circles individual concentrations). Analyte: peptide 
LFEYFK  
For subjects dosed with 0.12 and 0.24 mg/kg IdeS, in total 10 blood samples were 
collected up to 1 week post dose. The serum concentration versus time curve could be 
described by a multi-phase elimination curve (figure 7) and the main fraction of IdeS was 
eliminated during the first 24 hours post dosing. During the first 6 hours after dosing, the 
mean half-life was 4.1 (±2.6) hours at 0.12 mg/kg and 4.9 (±2.8) hours at 0.24 mg/kg. 
The Cmax was 5.0 (±2.5) mg/L at 0.12 mg/kg and 8.3 (±3.7) mg/L at 0.24 mg/kg. The Cmax 
and AUC increased with dose in humans.  
 
Figure 7 
 
Figure 7  Comparison of serum concentration of mean 
values of four peptides (peptide A: AFPYLSTK, peptide B: 
AIYVTDSDSNASIGMK, peptide C: GGIFDAVFTR and 

Page 13 of 42 
 
peptide D: LFEYFK) versus time profiles up to 24 hr post 
dose of IdeS after 15 infusion of 0.12 mg/kg or 0.24 mg/kg 
IdeS. 
 
2.2.4 Pharmacodynamics (PD) 
 
SDS-PAGE analysis revealed that complete conversion of the IgG pool into single 
cleaved IgG (scIgG) was observed in three out of eight subjects dosed with 0.01 mg/kg 
BW IdeS. ScIgG represents partially cleaved IgG where one of the two IgG heavy chains 
is cut by IdeS. A minor fraction of scIgG was further converted into F(ab’)2- and Fc-
fragments in these subjects and a weak reduction in plasma IgG was seen. At the next 
dose level, 0.04 mg/kg BW, the SDS-PAGE analysis showed partial effect in one 
subject, intermediate effect in one subject and close to full effect in one subject. 
 
The SDS-PAGE analysis of subjects dosed with 0.12 mg/kg BW of IdeS revealed that 
full or close to full effect was accomplished within 24 hours in all four subjects, i.e. IgG 
was fully cleaved into F(ab’)2- and Fc-fragments (figure 8A and 8B). Furthermore, 
maximum conversion into F(ab’)2- and Fc-fragments was reached six hours after dosing 
and this was confirmed using the PD-assay which showed that the level of intact IgG 
(plus scIgG) reached minimum levels six hours after dosing (figure 8). The PD-assay is a 
validated quantitative sandwich-ELISA based on a Fab-specific capture and an Fcγ-
specific detector that measure intact IgG and scIgG, but not the F(ab’)2/Fcγ-fragments 
generated through IdeS cleavage. 
 
In subjects dosed with 0.24 mg/kg BW of IdeS the IgG pool was converted into scIgG 
already during dosing and maximal effect was accomplished 2-6 hours after dosing in all 
four subjects (see SDS-PAGE in figure 8A and B). Thus, IgG cleavage was more rapid 
at the highest dose level (i.e. 0.24 mg/kg BW), compared to the lower dose (i.e. 0.12 
mg/kg BW). The rapid cleavage of human IgG into F(ab’)2 and Fc seen with SDS-PAGE 
analyses was confirmed with the PD-assay which showed that 2-6 hours after dosing 
low plateau level was reached at less than 5% remaining IgG and it was concluded that 
this signal mainly originated from scIgG (figure 8). Newly synthesized intact IgG was 
again detectable in serum two weeks after dosing in all subjects and after three weeks 
the level of intact IgG had further increased and constituted the main IgG fraction in 
serum (figure 9). See figure 10 for a summary of the SDS-PAGE analysis results. 
 
 
 

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Figure 8A 
 
 
 
 
 
 
 
 
 
 
Figure 8B 
 
Figure 8A&B. SDS-PAGE analysis of serum from subjects dosed with A) 0.12 mg/kg and B) 0.24 
mg/kg IdeS showing protein banding pattern from pre-dosing and up to 24 h after dosing. Intact 
IgG and single-cleaved IgG (scIgG), Fc and F(ab’)2 are indicated in the figure. A marker 
containing a mix of human IgG, scIgG, F(ab’)2 and Fc was also loaded on the gels (last lane). A 
comparison of the two dose groups shows that IgG cleavage is more rapid in the higher dose 
group. 

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Figure 9  
 
 
 
 
 
 
 
 
 
 
 
 
Figure 9. Serum IgG levels in serum from subjects in the two highest dose groups 
determined using the ELISA PD method performed by Covance laboratories. A, C & 
E) 0-64 days. B & D) 0-72 hours. 
 
 

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Figure 10A 
 
Figure 10A. SDS-PAGE analysis of serum from one subject in the 0.24 mg/kg BW illustrating that 
newly synthesized IgG can be detected after 14 days and has further increased after three weeks 
to constitute the main IgG fraction in serum. 
 
 
 
 
 
 
 
 
 
 
 
 

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Figure 10B 
 
 
Figure 10B. Scoring of the effect A) 2 hours and B) 24 hours after administration of IdeS or 
placebo. The effect was scored as “No effect”: intact IgG represents the dominating IgG-band, 
“Partial”: scIgG represents the dominating IgG-band or “Full effect”: scIgG is close to non-
detectable as the result of conversion to F(ab’)2 and Fc. A representative SDS-PAGE showing the 
different categories is incorporated in the figures and the different cleavage products are marked. 
*Serum (2 hours) was not available from group 1. 
 
2.2.5 Immunogenicity 
 
In the first human IdeS study special precautions were taken to prevent hypersensitivity 
reactions. IdeS originates from Streptococcus pyogenes and it is previously known that a 
significant proportion of the population has preformed IgG against IdeS (HMed Doc. No. 
2012-041). Anti-IdeS IgE (>0.10 kU/L) has not been detected in any individual tested so 
far. However, it is presumed that individuals with preformed IdeS antibodies of both IgE 
and IgG type have an increased risk of allergic reactions against IdeS. Therefore, 
specific in vitro test systems (IdeS-ImmunoCap) for the quantitative measurement of 
IdeS-specific IgE and IgG antibodies has been developed by Thermo Fisher Scientific, 
Uppsala, Sweden. The IdeS-ImmunoCap was used to screen study subjects before 

Page 18 of 42 
 
inclusion and subjects positive for IgE antibodies were not included in the study. 
Subjects with elevated IgG antibody titers (>15 mg/L) were also excluded from the first in 
man study. 
 
A total of 78 subjects were screened in the 11-HMedIdeS-01 study. None of the tested 
individuals had detectable IgE against IdeS but all tested individuals had detectable IgG. 
The median level of anti-IdeS IgG was 10.6 mg/L (range 2.1-90.8 mg/L) and 28% of the 
tested individuals had anti-IdeS IgG titers over 15 mg/L and were excluded from the 
study. Serum samples from included subjects were analysed for anti-IdeS IgG at the 
following time points; Day 1 (pre-dose), Day 2 (24 h post dosing), Day 3 (48 h), Day 4 
(72 h), Day 7 (1 week), Day 14, (2 weeks), Day 21 (3 weeks), Day 28 (4 weeks) and Day 
64 (2 months). The majority of the study subjects (dosed with a single dose of IdeS) 
responded with an increase of serum anti-IdeS IgG (figure 11). The response was non-
detectable one week after dosing but had reached close to peak levels two weeks after 
dosing. The median pre-dose level (all subjects) of anti-IdeS IgG was 5.3 mg/L (range: 
2.0-10.6 mg/L) and at day 14 the median level of all subjects dosed with IdeS was 104 
mg/L (range: 3.1-1744 mg/L). Two months after dosing the levels of anti-IdeS IgG had 
started to decrease in the majority of individuals and the median anti-IdeS IgG level of all 
subjects dosed with IdeS was 87.8 mg/L (range: 10.5-764 mg/L). Although the individual 
variation in the magnitude of the anti-IdeS IgG response was large there was clearly a 
stronger response among the subjects receiving 0.12 or 0.24 mg/kg IdeS compared to 
subjects receiving 0.01 or 0.04 mg/kg. It can be concluded that the anti-IdeS IgG 
response is very similar in kinetics and magnitude to the response reported for other 
drugs of bacterial origin, such as streptokinase and staphylokinase (Collen et al., 1997; 
Declerck et al., 1994; Mainet et al., 1998).  
 
Figure 11 
 
Figure 11. Anti-IdeS IgG levels in human serum from subjects receiving a single dose, A) 0.01 
mg/kg, B) 0.04 mg/kg, C) 0.12 mg/kg and D) 0.24 mg/kg, of IdeS. Day 1 represents the pre-dose 

Page 19 of 42 
 
sample. Note the different y-axis scales. The samples were analysed using the IdeS-ImmunoCAP 
(Thermo Fisher Scientific/Phadia) on a Phadia® 250 instrument. The cut-off (LLOQ) for IgG was 
2 mg/L.  
3 Primary Objectives 
 
This study will be an open label design to assess the efficacy of IdeS® in eliminating  
DSAs in HS patients who are DSA+ and flow cytometry (FCMX) crossmatch + at time of 
transplant. Safety determinations will be aimed at assessments of any side effects 
associated with IdeS® administration and risk for infectious complications associated 
with IdeS® therapy for prevention of ABMR. Limited efficacy determinations will include 
incidence of allograft rejection, DSA levels at multiple times post-transplant (Day 0, 30, 
90 and 180), determinations of renal function, proteinuria (day 0 through day 30), and 
pathologic assessments of allograft biopsies at 6M after completion of IdeS® therapy. 
Patients will be followed and assessed for infectious risk after transplantation as well.   
 
3.1 Major Secondary Objectives 
  
To determine if IdeS® treatment, can prevent or significantly reduce ABMR episodes 
and C4d deposition in incompatible allografts transplanted to highly-HLA sensitized 
patients from ~25% to <5% in CMX+ donor-specific antibody (DSA)+ patients. Assess 
allograft function up to 6 M post-transplant, determine renal function using SCr, MDRD 
GFR calculations and DSA levels. We will also record any late ABMR episodes after 
IdeS® therapy. This study protocol is shown in Figure 4. 
 
3.2 Inclusion Criteria 
 
 End-stage renal disease awaiting transplantation on the UNOS list. 
 No known contraindications for therapy with IVIG10%/Rituximab, plasmapheresis 
(PLEX) or IdeS®. 
 Age 18-70 years at the time of screening. 
 Calculated PRA (CPRA)> 50% demonstrated on 3 consecutive samples, Patient 
highly-HLA sensitized and a candidate for DD transplantation after 
desensitization at CSMC. 
 At transplant, patient must have donor-specific antibody/ crossmatch positive 
(DSA/CMX+) non-HLA identical donor. 
 Pre-transplant vaccination with Streptococcus pneumoniae and Nisseria 
meningitides 
 Subject/Parent/Guardian must be able to understand and provide informed 
consent. 
 
3.3 Exclusion Criteria 
 
 Use of IVIG 7 days prior to planned IdeS® administration  
 Recipients of Extended Criteria Donors (ECD) or Living Donors (LD)  
 Lactating or pregnant females. 
 Women of child-bearing age who are not willing or able to practice FDA-
approved forms of contraception. 
 HIV-positive subjects. 
 Subjects who test positive for HBV and HCV DNA and/or RNA PCRs. 

Page 20 of 42 
 
 Subjects with active TB. 
 Subjects with selective IgA deficiency, those who have known anti-IgA 
antibodies, and those with a history of anaphylaxis or severe systemic responses 
to any part of the clinical trial material. 
 Subjects who have received or for whom multiple organ transplants are planned. 
 Recent recipients of any licensed or investigational live attenuated vaccine(s) 
within two months of the screening visit (including but not limited to any of the 
following: 
o Adenovirus [Adenovirus vaccine live oral type 7] 
o Varicella [Varivax] 
o Hepatitis A [VAQTA] 
o Rotavirus [Rotashield] 
o Yellow fever [Y-F-Vax] 
o Measles and mumps [Measles and mumps virus vaccine live] 
o Measles, mumps, and rubella vaccine [M-M-R-II] 
o Sabin oral polio vaccine 
o Rabies vaccines [IMOVAX Rabies I.D., RabAvert]) 
 A significantly abnormal general serum screening lab result defined as a WBC < 
3.0 X 103/ml, a Hgb < 8.0 g/dL, a platelet count < 100 X 103/ml, , an SGOT > 3X 
upper limit . 
 Individuals deemed unable to comply with the protocol. 
 Subjects with active CMV or EBV infection as defined by CMV-specific serology 
(IgG or IgM) and confirmed by quantitative PCR with or without a compatible 
illness.  
 Subjects with a known history of previous myocardial infarction within one year of 
screening. 
 Subjects with a history of clinically significant thrombotic episodes, and subjects 
with active peripheral vascular disease. 
 Subjects with Protein C and Protein S deficiency  
 Use of investigational agents within 4 weeks of participation. 
 Known allergy/sensitivity to IdeS® infusions 
 
4 Study Design & Methods 
 
Background: This is a single center, Phase I/II, open label exploratory study.  The trial 
will primarily examine the safety and tolerability of IdeS® (Hansa Medical, Lund Sweden) 
given 4-6 hours prior to kidney transplantation to reduce or prevent complement-
dependent, antibody-mediated rejection (ABMR) in 20 subjects (adult) who are highly-
HLA sensitized (HS) as determined by the Calculated Panel Reactive Antibody Test 
(CPRA), have undergone desensitization with IVIG + rituximab and/or plasmapheresis 
and are awaiting LD/DD kidney transplant at Cedars-Sinai Medical Center. Patients will 
be screened for study eligibility once transplant offers are entertained. If the patient 
agrees to participate in the study, a donor-specific crossmatch will be performed to 
detect anti-HLA antibodies and donor-specific anti-HLA antibodies (DSA) which are 
associated with ABMR and/or graft loss. DSA will be detected using solid phase assay 
systems currently utilized at the Cedars-Sinai Medical Center HLA Laboratory (Dr. 
Nancy Reinsmoen, Director, Phone: 310-423-4979)10. These anti-HLA antibodies may 
result naturally or from previous pregnancy, transfusions, or prior transplants. If 
acceptable crossmatches and DSA levels are seen after desensitization, twenty patients 
will proceed to DD transplantation as previously described23-25. Patients receiving 

Page 21 of 42 
 
transplants will have pre-transplant labs for screen ADA, DSAs, FCMX, C3 and C4 
obtained as outlined (See Study Protocol in Appendix A). In addition to the standard 
post-transplant immunosuppressive protocol, all patients will receive 0.24mg/kg IdeS® 
on day 0 on call to the OR prior to transplant procedure. Pre-medications will be given to 
patients as a precaution with Solumedrol 40mg IVP, Tylenol 650mg PO and Benadryl 
50mg PO to minimize the risk of infusion reactions.Crossmatch and DSA tests will also 
be assessed on day 1 post-transplant to determine the effect of IdeS®. A protocol biopsy 
will be performed at 6M to assess the allograft for evidence of ABMR, including C4d 
staining using Banff 2013 criteria8, 16. Since ~25% of HS patients experience ABMR post-
transplant and 80% of these ABMR episodes occur in the 1st post-transplant month, we 
feel the assessment of the potential impact of IdeS® therapy is best assessed in this 
time period.  Patients who have evidence of allograft dysfunction will have non-protocol 
biopsies for cause. After completion of the IdeS® therapy, patients will be followed up to 
6M to assess allograft function and ABMR episodes as well as DSAs. A protocol biopsy 
will be performed at 6M. The protocol is summarized in Fig. 12.   
Figure 12 
 
The entered subjects will be followed to determine if the use of IdeS® for prevention of 
ABMR in this high risk transplant population is safe and without infectious risks. In 
addition, we will determine the proportion of who developed evidence of ABMR within 
6M of completion of the study. We will assess the transplanted patients to determine the 
number who sustain a viable and functioning kidney allograft for 6 months.  All subjects 
will be evaluated on an intent-to-treat basis.  The subject accrual rate will be limited to no 
more than five subjects per month in the initial three months to assure safety to all 
subjects. Repeat laboratories will be performed at the completion of IdeS® therapy to 
determine effect on levels and correlation with any potential events. A detailed analysis 
of the study is discussed below. 

Page 22 of 42 
 
4.1 Study Analysis 
  
This single-center, Phase I/II, trial is designed to examine the safety, tolerability and 
limited efficacy of human IdeS® (0.24mg/kg) given as per protocol (Appendix A) in 20 
subjects (adults only) who are highly-HLA sensitized and are awaiting DD kidney 
transplant. Patients considered for this study will be desensitized using high-dose IVIG + 
rituximab and/or plasmapheresis8, 23-25.  Patients who have received IVIG within 7 days 
from transplant offer will be excluded from study in order to minimize interactions with 
IdeS® infusion and circulation of IgG from IVIG infusion27. Once transplant offers are 
entertained, a donor-specific crossmatch will be performed to detect anti-HLA antibodies 
which are associated with risk for ABMR. The specifics of our patient selection for 
desensitization, desensitization protocol, CMX testing and post-transplant protocols are 
outlined below: 
 
4.2 Defining the Sensitized Patient   
 
For the purposes of this study, we define HLA sensitization as a patient awaiting kidney 
transplantation on the UNOS waitlist who has a CPRA of >50% who also has 
demonstrable DSA using luminex bead technology and a history of sensitizing events 
(previous transplants, blood transfusions and/or pregnancies). These individuals must 
also have sufficient wait time on the UNOS list to allow for frequent offers with a history 
of positive crossmatches (DD) or an incompatible (LD) with a positive flow cytometry 
(FCMX), complement-dependent cytotoxicity (CDC+) crossmatch23-25.  
 
4.3 Defining ABMR  
 
For purposes of this investigation, antibody-mediated rejection (ABMR) is defined as 
follows: 
 
 Deterioration of allograft function in a high-risk transplant recipient (i.e. 
sensitized patient with history of DSAs) measured by serum Cr and eGFR 
(defined as a decline >20% from baseline).    
 Association with the presence of DSA (usually increasing in strength) 
measured by luminex techniques. 
 Biopsy evidence of capillaritis, inflammation and C4d deposition.  
 
Figure 13 below shows the course of a highly-sensitized (HS) patient who developed 
ABMR after receiving desensitization for incompatible kidney transplantation.  Note, 

Page 23 of 42 
 
DSAs increase with evidence of allograft dysfunction. This is associated with significant 
biopsy findings including evidence of complement activation and inflammation. 
 
Figure 13 
 
 
Figure 13 shows the course of DSAs after transplantation in this HS patient who received 
desensitization with IVIG + rituximab prior to transplant. Three DSAs were present at transplant 
(two moderate strength and one low strength) as determined by a Relative Intensity Scale (RIS) 
where 0 points is given for a negative DSA, 2 for low strength (1000-2000 MFI), 5 for moderate 
(2000-5000 MFI)  and 10 for high (>5000 MFI). The course of SCr, DSAs and biopsy are shown 
as well as responses to treatment with IVIG + rituximab.  
 
The presence of DSAs has a strong correlation with C4d deposition and biopsy evidence 
of ABMR3, 9, 12-14. Thus, this study will assess the ability of IdeS® to alter or prevent 
ABMR in DSA + patients. Important observations will be the assessment of efficacy of 
IdeS® in enzymatic cleavage of DSAs, the duration of this effect and the potential for 
rebound DSA responses after this unique therapy. We will also assess development of 
anti-IdeS® antibodies and determine if these responses are altered by desensitization. 
  
4.3.1 Treatment of Antibody Mediated Rejection (ABMR) 
 
Biopsy-proven rejection episodes are treated with “pulse” methylprednisolone 
(10mg/kg/day, max 1000mg for >100kg for 3 days) and anti-thymocyte globulin 
(1.5mg/kg daily X 4) for cell-mediated rejection episodes that are unresponsive to pulse 
steroids. For patients experiencing ABMR, patients will initially receive pulse 
methylprednisolone  (10mg/kg/day, max 1000mg for >100kg) IV daily x 3 doses then, 
depending on severity, IVIG 10% solution 2gm/kg (max 140g for >70kg) IV X1 dose 
followed by rituximab (375mg/m2) IV X1 dose. In cases where rapid deterioration of 
allograft function is seen and/or thrombotic microangiopathy is seen on biopsy, the 
patient will receive plasma exchange X3-5 sessions followed by anti-C5 (Eculizumab®) 
IV weekly X4 weeks (1200mg week #1 followed by 900mg/ weekly for 3 additional  

Page 24 of 42 
 
weeks).  Efficacy of therapy will be assessed by determining renal functional 
improvement, monitoring DSA responses and repeat allograft biopsies, if needed.  
 
4.4 IVIG/Rituximab Desensitization Protocol  
 
All HS who meet criteria for desensitization will receive IVIG 10% solution (2.0 g/kg 
[maximum 140 g per dose] on days 1 and 30) and rituximab (1 g administered on day 
15).  When a DD kidney offer becomes available, a donor-specific FCMX is performed 
pre-transplant. An acceptable CMX is defined as a negative complement-dependent 
cytotoxicity (CDC), at least at a 1:2 dilution of sera. A positive T-and B-cell FCMX with a 
shift of less than 225 channel shifts (CS) is also acceptable (negative: <100 mean 
channel shifts [MCS] for B cell and <50 MCS for T cell). Solid-phase antibody analysis 
was also used to define the specificity of the antibodies detected, to follow the effect of 
desensitization, and the strength of DSA as reported previously23-25.  Since the B-cell 
cytotoxicity and FCMX crossmatches are falsely elevated by rituximab, a heavier 
reliance on T-cell FCMX data and DSA values (<100,000 standard fluorescence intensity 
[SFI] units) is used as the primary determinants of CMX acceptability as described 
previously and illustrated below. 
 
An analysis of the effects of the IVIG + rituximab desensitization protocol on DSA levels 
is shown in Figure 14A. Figure 14B shows the relationship of DSA levels and FCMX 
results. The data confirm that a cutoff of ~225 channel shifts (CS) for FCMX and DSAs 
<100,000 SFI units is associated with lower risk for ABMR compared with higher DSA 
levels and FCMX >225 CS. 
 
Figure 14A 
 
 
 
Figure 14A:  Sequential antibody profiles subsequent to one round of immunomodulatory therapy 
(IVIG + rituximab).The value of each data point is represented as the average of all single antigen 
beads equal or greater than 20,000 SFI.  Patient 4853 serum contained anti-HLA class I 
antibodies only.  Sera from patients 901, 301, 15622, 17075, 19211, 19521, and 25059 contained 
both class I and class II anti-HLA antibodies.  
 

Page 25 of 42 
 
Figure 14B 
 
Figure 14B: Determining acceptable single antigen bead strength by using the sum of the highest 
DSA values for class I and class II beads versus BPFXM. 
 Patients with no ABMR episodes, 
 patients with an ABMR episode within 42 day. 
 A patient with ABMR within 50 to 200 days 
and patients with 
 ABMR episodes after 200 days.   
 
By using the criteria outlined, 74% (80/108) HS (C PRA>80%) DD recipients treated with 
desensitization (1/06-12/09) were transplanted. A total of 26% (28/108) patients 
remained on the waitlist during this period with mCPRA 95.  Four of these patients were 
transplanted in 2010.  Of the 80 patients transplanted, 42 (53%) were transplanted with 
a positive donor specific T and/or B cell flow cytometry XM.  A total of 19 (24%) patients 
experienced ABMR +/- CMR ranging from 3 to 535 days post-transplant with a median of 
109 days. Seven of these patients were diagnosed with ABMR +/- CMR within the first 
42 days.  Two patients were diagnosed with late ABMR +/- CMR at post-transplant days 
144 and 249.  One of these patients had CMV detected by PCR before the diagnosis of 
ABMR and one patient had CMV detected by PCR at the time of ABMR diagnosis..  
Another patient had Parvovirus B19 positive PCR reaction prior to the diagnosis of 
ABMR (post-transplant day 535).  One patient was noncompliant (post-transplant day 
139) and lost the graft.  Twenty-eight patients (mCPRA 91) were transplanted with a 
negative donor specific flow cytometry XM.  Pretreatment samples were available for 25 
of these 28 patients and showed all pretreatment XMs were negative with the donor 
samples. Among these 28 patients, none had ABMR and 8 had CMR.  The CMR 
occurred between 15 and 773 days post-transplant with the median time at 58 days.  A 
total of 10 patients received zero HLA ABDR mismatched grafts (mCPRA 90), one had 
ABMR after 101 days post-transplant and one had CMR at 404 days post-transplant.  
 
In this data set of 108 patients, we saw an ABMR rate of 24% using careful selection 
criteria based on FCMX and DSA data at transplant. When compared a concomitant 
group of non-sensitized patients transplanted during the same time period (N=190), we 
saw an ABMR rate of <1% in this non-sensitized, low risk group. Thus ABMR is very rare 
in non-sensitized patients and in patients who are DSA + but FCMX negative who have 
received desensitization prior to transplantation.  
 
 
 
 

Page 26 of 42 
 
4.5 Monitoring for AE/SAEs Post-Transplant in HS Patients  
 
Adverse events (AEs) and serious adverse events will be monitored post-transplant. 
These include careful attention to infectious complications potentially associated with 
IdeS® therapy.  
 
Infectious complications associated with IVIG + rituximab desensitization and 
alemtuzumab induction therapy followed by maintenance therapy with tacrolimus, MMF 
and prednisone have been assessed by our group. Briefly, we evaluated 170 patients 
who were desensitized with IVIG + rituximab followed by alemtuzumab induction and 
maintenance therapy with tacrolimus, MMF and steroids. This was compared to a 
concomitant group of non-sensitized, low-risk transplants (N=191) who did not receive 
IVIG, rituximab or alemtuzumab (induction with IL-2R blockers). A careful analysis of all 
infections and serious infections that occurred over the next 4 years was compiled and is 
shown in Figure 15A &15B.  Briefly, these data show that the use of this desensitization  
 
Figure 15A 
 
protocol followed with alemtuzumab induction does not increase the risk for common or 
serious infections post-transplant compared to a low risk group of patients. Serious 
infections were defined as any viral infection and fungal or bacterial infections requiring 
i.v. antibiotics or hospitalizations19. Thus risk for infections in the study group (IdeS®) 
after desensitization will likely be similar and comparable to non-sensitized patients.  All 
patients entered into this study will receive vaccinations for Streptococcus pneumoniae 
and Neisseria meningitides pre-transplant.   
 

Page 27 of 42 
 
In addition, all patients treated with IdeS® will also receive antibiotic prophylaxis with 
ciprofloxacin for 4 weeks post-transplant. It is also noted that our protocol includes a 
post-transplant dose of IVIG 2 gm/kg (maximum 140 grams) administered at 7 days 
post-transplant. This will provide additional anti-infective support during the IgG 
reconstitution after IdeS® therapy. 
 
Figure 15B 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
15A & B: This figure shows the proportion of kidney transplant recipients who developed 
infections (all infections 15A, or serious infections 15B) post-transplant. Patients were in the low-
risk group (non-Ritux #191) who did not receive IVIG/ritux or alemtuzumab or (Ritux #171) who 
received desensitization with rituximab, IVIG followed by transplantation. Follow up for up to 45 
months shows that infection rates are similar. The commonest infection was urinary tract infection 
in both groups. The incidence of CMV was greater in the non-Ritux group while there were more 
BK infections in the Ritux group. No patients in the Ritux group developed PTLD or PML while 2 
patients in the non-Ritux group developed PTLD.  
 
4.6  Infection Prophylaxis Protocols and Viral Monitoring Post-
Transplant  
 
All study patients, regardless of their cytomegalovirus (CMV) status, receive IV 
ganciclovir while inpatients and valganciclovir as outpatients for 6 months, with dose 
adjustments for renal function. Fungal prophylaxis was accomplished with fluconazole 
100 mg daily for 1 month. Pneumocystis jirovecii pneumonia and bacterial prophylaxis 
is accomplished with trimethoprim 80 mg and sulfamethoxazole 400 mg daily for 12 
months. 
 
Viral polymerase chain reaction assays for CMV, Epstein Barr virus, Parvovirus B-19, 
Polyoma virus BK and JC will be performed on study patients monthly for 6 months post-

Page 28 of 42 
 
transplantation. Methodologies used for monitoring viral replication have been described 
previously 25. 
 
4.7  Outcomes of HS Patients vs. Non-Sensitized Patient Cohort  
 
As part of the suggested revisions of this protocol, we have evaluated a group (N=170) 
of patients who underwent desensitization with IVIG + rituximab and were transplanted 
(2006-2010). This was compared to a group of non-sensitized patients who were 
transplanted during the same time period who did not receive IVIG, rituximab or 
alemtuzumab induction. The patient characteristics are shown in Table 1 below.  Briefly, 
the only significant findings were the higher PRA in the Ritux group, more White (non-
Hispanics) in the non-Ritux group, more females in the Ritux group, more lymphocyte 
depleting agents in the Ritux group and significantly longer dialysis times for the Ritux 
group.  In Table 3, we see the outcomes up to 45 months post-transplant in the two 
groups. Briefly, there are no significant differences between the two groups in regards to 
patient and graft survival and infection rates however, there were more rejections in the 
Ritux group. As previously mentioned, the ABMR rate for sensitized patients (CPRA 
>80%) was 24% vs. <1% for the non-Ritux group.  
 
Table 3 
 
Table 3 shows patient survival, graft survival, and number of patients who developed 
Infections in the Ritux vs. non-Ritux group. 
 

Page 29 of 42 
 
Table 4 
 
Table 4  shows the overall survival by treatment group and risk for common viral 
injections post-transplant. Briefly, no differences were seen between the two groups for 
any type of infection or serious infections.  
 
5 Dosing of IdeS®   
 
IdeS is a clear colorless liquid. It is formulated at 10 g/L in PBS and intended for 
intravenous administration after dilution. Refer to table 5 for composition. 
Table 5. Study drug 
Ingredient 
Quantity  
(g/L) 
Function 
IdeS drug product 
10  
Active ingredient 
Phosphate buffered saline: 
 
 
Potassium Chloride (KCl) 
0.20  
Buffer 
Monopotassium Phosphate (KH2PO4 ) 
0.20  
Buffer 
Sodium Chloride (NaCl) 
8.0  
Buffer 
Disodium Phosphate (Na2HPO4) 
1.43  
Buffer 
 
5.1  Storage and Handling  
 
All patients will receive treatment with IdeS. IdeS will be supplied to the hospital 
pharmacy by Biovian in 7 mL vials packed into cartons containing 10 vials each. Vials 
should be kept dark at – 20°C. IdeS infusion solution will be prepared at the study unit. 
Administration will be performed using an infusion bag with a filter containing infusion set 
and an infusion pump. Details on preparation, labeling and administration of IdeS are 
described in the pharmacy manual. (see Appendix B). 
 
5.1.1 Collection, Transport & Shipping to the Laboratories 
Samples for Anti-IdesS Antibody Levels will be collected according to the protocol 
outlined in Appendix C.  These samples will be pooled and mailed to the 

Page 30 of 42 
 
laboratories (Addresses listed in Appendix C).  Thus, results will be available at 
the end of the study.   
 
5.2  Patient Monitoring 
 
Patients will be closely monitored for hypersensitivity reactions such as hives, urticaria, 
tightness of chest, wheezing, hypotension, and/or anaphylaxis during infusion of IdeS®, 
which are all common side effects of biological drugs. Patients will also be monitored for 
any signs of infections, although there were no signs of increased infection rates in 
healthy subjects who received IdeS. Patients with ongoing infections will not be included 
in the study. 
 
5.3 Adverse Drug Reactions 
 
A first in man single ascending dose study in 29 healthy subjects has previously been 
performed with doses up to 0.24 mg/kg BW with a favorable safety profile. Since IdeS 
degrades IgG there was concern that study subjects would have an increased risk of 
infection and that subclinical infections (e.g. pneumococci) would pose a problem. 
Therefore, subjects received antibiotic prophylaxis until plasma IgG levels had returned 
(>4.5 g/L) and there were no signs of an increased rate of infections within the study 
group. The adverse events that were reported, none of which were reported as serious, 
were as anticipated from to the biological nature of the drug. Hence, headache and 
fatigue were more common in the IdeS treated subjects compared to placebo. One 
possible infusion reaction was reported among the placebo treated subjects and one 
among the IdeS treated, the latter resolved within 15 minutes after treatment with 
antihistamine and glucocorticoids and the infusion was completed. All adverse events 
were mild or moderate. 
 
5.3.1 Ides and Proteinuria  
 
A phase I, first in man, double blind and randomized study with single ascending doses 
of IdeS has been conducted and the objective was to assess the safety, efficacy, 
pharmacokinetics, and immunogenicity of IdeS in healthy human subjects following 
intravenous administration. 
A total of 29 healthy subjects were included and randomized into four dose groups. The 
subjects in each dose group were randomized to either IdeS or placebo. The starting 
dose was 0.01 mg/kg body weight (BW) (nIdeS = 8 and nPlacebo = 4) and after evaluation 
by the data monitoring committee the dose was stepwise increased to 0.04 mg/kg BW 
(nIdeS = 4 and nPlacebo = 2), 0.12 mg/kg BW (nIdeS = 4 and nPlacebo = 1) and 0.24 mg/kg BW 
(nIdeS = 4 and nPlacebo = 2). The subjects were followed until day 64 after dosing with more 
intensive monitoring during the first week. All subjects were male Caucasians with a 
median age of 23 years (range: 20-41), weight 76 kg (range: 59-100) with a body mass 
index of 23 kg/m2 (range: 20-30) and there were no statistical significant differences in 
demographics between the groups.  
 

Page 31 of 42 
 
As part of the safety assessment urinalysis (U-glucose, U-hemoglobin and U-protein) 
was performed using Multistix (Siemens, Germany). The proteinuria was scored as 
negative, trace, +1 (0.3 g/L), +2 (1.0 g/L), +3 (3.0 g/L) and +4 (≥20 g/L) according to the 
manufacturer’s instructions. A transient and mild proteinuria was observed 24-48 hours 
after dosing in subjects administered an IdeS dose that resulted in significant cleavage 
of IgG (Fig. 16). In the placebo treated group the proteinuria varied between negative 
and +1 during the 64 day period. In the highest dose group, where IgG was fully cleaved 
into F(ab’)2 and Fc within 2-6 hours, peak levels of proteinuria at +2 was observed in 
three of four subjects. This peak probably reflected the clearance of IgG cleavage 
products from the circulation. None of the treated subjects had a strong elevation in 
proteinuria and in all subjects the values were rapidly normalized. No subjects had any 
signs of hematuria correlating to IdeS treatment.  
 
 
 
Figure 16. Proteinuria was monitored as a safety assessment throughout the study. 
Multistix (Siemens) were routinely used at the hospital and transient proteinuria was 
detected in several subjects which correlated to IgG cleavage. A) Subjects given placebo 
(n = 9). B) Subjects given a single dose of 0.24 mg/kg BW IdeS (n = 4). Data represents 
proteinuria in individual subjects at the indicated time-points after treatment. 
To minimize adverse outcomes, patients with extended criteria donors (ECD) will be 
excluded from the study.  The level of proteinuria post Ides is not clinically significant 
since proteinuria rapidly decreases to baseline day 3-4 after IdeS® administration. 
Proteinuric effects of IdeS will be monitored closely post IdeS for the first 4 weeks after 
transplant (see appendix A) to determine if there is a sustained effect.  
 
 
 
 

Page 32 of 42 
 
6 Therapy Stopping Points 
 
As indicated previously, the study will be halted and re-evaluated by the Data and Safety 
Monitoring Board (DSMB) if any patient in the study group develops SAEs or evidence of 
severe infusion related or infectious complications.  Reassessment of the study goals 
and complications will be done and discussed with Hansa Medical, the DSMB and FDA 
prior to proceeding (see appendix D).  
 
 
7 Statistical Analysis 
 
Due to the exploratory nature of this study that involves safety endpoints only and the 
small sample size that is not powered for efficacy end points, our primary objective will 
be to assess safety end points and limited efficacy. Most important will be tolerability in 
the ESRD population and determination of the effects of IdeS® treatment on circulating 
DSAs as well as the durability of the effect and efficacy in reducing the number and 
severity of ABMR episodes.  We will however plan to assess biopsies at 6M to 
determine if there are durable effects of IdeS® in prevention of ABMR both acute and 
chronic. 
 
 

Page 33 of 42 
 
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Pharmacol, 83 (2013), 1268-75. 
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Villicana, and S. C. Jordan, 'Rituximab and Intravenous Immune Globulin for 
Desensitization During Renal Transplantation', N Engl J Med, 359 (2008), 242-51. 
25 
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Ivig and Rituximab', Transplantation, 95 (2013), 852-8. 
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Page 35 of 42 
 
m.fl. Pharmacokinetics of intravenous immunoglobulin and outcome in Guillain-Barré 
syndrome. Ann Neurol. november 2009;66(5):597–603. 
 

Page 36 of 42 
 
Appendix A 
Study/Protocol Title: “A Phase I/II Trial to Evaluate the Safety & Tolerability of the Human IgG endopeptidase (IdeS®) for Elimination of DSAs 
& Prevention of Antibody-Mediated Rejection Post-Transplant in Highly-HLA Sensitized Patients” 
Study  visit 
Screening 
Transplant Day 
0 
1 h ± 15 
min 
2h ± 
15 min 
6h ± 
30mi
n 
Day  
1 ± 
2h   
Day 
2 ± 
2h 
Day 
3 ± 
6h 
Day 
4 ± 
1d 
Day 
5 ± 
1d 
Day 
7 ± 
3d 
Day 
14 
± 
3d 
Day 
21 
± 
3d 
Day 
30 ± 
3d 
Day 
90 ± 
7d 
Day 180 ± 
30d 
Prophylaxis: Ganciclovir for 
inpatients and Valganciclovir for 
outpatients 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum Igg  
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
PPD/Quantiferon Test 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent   
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion criteria review  
X 
 
 
 
 
 
 
 
 
 
Medical History  
X 
 
 
 
 
 
 
 
 
 
Complete Physical Exam  
X 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs/weight  
X 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
12-lead ECG (SOC)- w/in 6M 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-Ray (SOC) --w/in 6M 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety laboratory tests  
(CBC, CMP, UA) 
X 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Total Protein,  
Urine Creatinine (UTP/UCr) 
(if urine available) 
 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Review Historical Serologies for 
HIV, HBV, HCV, CMV, & EBV  
X 
 
 
 
 
 
 
 
 
 

Page 37 of 42 
 
 
 
EBV, CMV, PBK, PJC DNA PCR  
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Pregnancy test (for WOCP)  
X 
X 
 
 
 
 
 
 
 
 
 
Estimated GFR  
(using MDRD equation)  
X 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Study  visit 
Screening 
Transplant Day 0 
1 h ± 15 
min 
2h ± 
15 
min 
6h ± 
1h 
Day  
1 ± 
6h   
Day 
2 ± 
6h 
Day 
3 ± 
6h 
Day 
4 ± 
6h 
Day 
5 ± 
1d 
Day 
7 ± 
2d 
Day 
14 ± 
3d 
Day 
21 ± 
7d 
Day 
30 ± 
7d 
Day 
90 ± 
14d 
Day 180 ± 
30d 
Pneumococcal Vaccine & 
Meningcoccal Vaccine 
(Menactra® & Menomune®)  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Desensitization w IVIG + 
Rituximab*  
X 
 
 
 
 
 
 
 
 
 
Screen ADA 
(Freeze and batch out/analyze at 
the end of the study)  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ADA  (Sent Out)  
X 
(pre-dose) 
 
 
 
X 
 
 
 
X 
X 
 
X 
X 
X 
C3, C4 Levels  
 
 
 
 
 
X 
 
 
 
 
X 
PD analysis (Sent Out)  
X 
(pre-dose) 
X 
 
X 
X 
 
 
 
X 
X 
X 
X 
PK analysis (Sent Out) 
 
X 
(pre-dose) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Donor Specific Antibodies (DSA) 
X 
 
 
X 
X 
 
 
 
 
 
X 
X 
X 
IdeS® Administration 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Alemtuzumab Administration** 
 
 
 
 
 
X 
 
 
 
Ciprofloxacin Prophylaxis  
daily x 30d 
 
X 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Repeat IVIG Post Tx 
 
 
 
 
 
 
 
X 
 

Page 38 of 42 
 
Revised 10/15/15 
*   Or Plasmapheresis [PLEX] 
** Give alemtuzumab 4 days +/- 6 hours after IdeS administration 
 
 
CNI Levels 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Allograft biopsy 
 
 
 
 
 
 
 
 
 
X 
Adverse Event Monitoring 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X