Improved Induction and Maintenance Immunosuppression in Kidney Transplantation
Condition: End-stage Renal Disease
MeSH terms: Kidney Failure, Chronic
Study type: Interventional
Phase: Phase 4

Summary: 
      This 2 x 2 sequential factorial study evaluates two potential improvements to the standard
      immunosuppression regimen used at the investigators' institution to prevent rejection of
      transplanted kidneys. These two potential improvements are each applied in sequence to half
      of the study patients, creating 4 study arms; the other half receive the standard treatment.
      The two potential improvements are:

        1. Administering the immunosuppression induction agent rATG ("rabbit anti-thymocyte
           globulin") in a single dose at the time of transplantation, instead of in the usual
           series of 4 smaller doses over 6 days.

        2. After 6 months, modifying the maintenance immunosuppression used to prevent rejection by
           replacing the drug tacrolimus with mycophenolate mofetil (MMF).

      The two interventions, spaced sequentially six months apart, enable independent analysis of
      the two treatments so long as it can be shown that there is no synergistic interaction
      between them.
    

Detailed description: 
      The two treatment innovations in this study of immunosuppression in kidney transplantation
      are aimed at making the transplanted kidney function sooner and last longer than is usual
      with standard immunosuppression regimens, but without increasing the likelihood of rejection.

      The first innovation, delivering the induction agent rATG in a single large dose rather than
      as a series of smaller doses over 6-8 days, is expected to produce better graft function
      right away, possibly by reducing some of the injury to the kidney that accompanies the
      restoration of blood flow during transplantation ("reperfusion injury"). Some evidence has
      been developed by investigators elsewhere to suggest this will happen.

      The second innovation, replacing tacrolimus with MMF after 6 months, is intended to eliminate
      a well-established major cause of ongoing toxic damage to the kidney. While tacrolimus does a
      good job of preventing rejection, the cost in continuing toxic injury to the kidney is high,
      leading inevitably to eventual graft failure, the inability of the transplanted kidney to
      continue filtering the blood and making adequate volumes of high-quality urine.
    

Intervention name(s): rabbit anti-thymocyte globulin - single dose; mycophenolate mofetil; rabbit anti-thymocyte globulin - 4 doses; sirolimus; tacrolimus
Intervention type(s): Drug; Drug; Drug; Drug; Drug
Intervention description(s): A single 6 mg/kg dose of rATG administered intravenously over 24 hours, beginning before kidney transplantation. Administration of the drug is begun as early as practical, usually after general anesthesia has been established but before surgery has started. The rATG is therefore administered for about two hours before blood flow is restored to the kidney undergoing transplantation.; Patients are switched approximately 6 months after kidney transplantation from maintenance immunosuppression with tacrolimus and sirolimus to maintenance with mycophenolate mofetil and sirolimus. The drug is administered orally, taken daily, with dose adjusted in proportion to measured blood levels, and is required indefinitely to prevent rejection of the transplanted kidney.; 6 mg/kg rabbit anti-thymocyte globulin delivered in 4 doses of 1.5 mg/kg each, the first administered at the time of kidney transplantation. Subsequent doses are administered on days 2, 4, and 6.; Oral maintenance immunosuppressant administered daily, dose adjusted according to measured serum trough levels, continued indefinitely to prevent kidney rejection; Oral maintenance immunosuppressant, taken daily, dose adjusted to maintain target blood trough levels, required indefinitely to prevent kidney rejection.
Other intervention name(s): Thymoglobulin; rATG; CellCept; MMF; mycophenolic acid; Myfortic; Thymoglobulin; Rapamune, rapamycin; FK506; ProGraf
Intervention MeSH terms: Mycophenolic Acid; Sirolimus; Tacrolimus; Thymoglobulin; Antilymphocyte Serum
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Induction; rATG; Calcineurin-inhibitor withdrawal