Clonal Deletion on Living-Relative Donor Kidney Transplantation

Study Overview
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Brief Summary
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The objective of this trial is to determine if clonal deletion before kidney transplantation can effectively reduce the need for post transplant immunosuppression. The investigators will adapt a DAWN (Drugs (immunosuppressants) Added When Needed) treatment protocol to assess the effect of clonal deletion and closely monitor acute rejection, renal function, and graft survival. 15 patients eligible for the study as described below will be enrolled.

Detailed Description
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The objective of this trial is to determine if clonal deletion can effectively reduce the need for post transplant immunosuppressive medicine. Emphasis will be placed on adverse events that are associated with clonal deletion. The investigators will assess whether DAWN (Drugs (immunosuppressants) Added When Needed) is feasible in living-relative donor kidney transplantation and the effectiveness of clonal deletion treatment on the rate of rejection, patient survival, and graft function from day 0 to 12 months after transplantation. Numbers of patients on single drug and dual therapy immunosuppression will be counted. Additionally, the investigators would assess time to immune event (rejection or antibody), the severity of acute rejection or antibody mediated rejection by Banff criteria, the incidence of delayed graft function (defined as the need for post-transplant dialysis), and the incidence of adverse events including infection, grade 3 and above non-hematologic toxicities, and grade 4 hematologic toxicities.

Official Title
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A Prospective, Open-Label, Pilot Study of Clonal Deletion on Living-Relative Donor Kidney Transplantation

Conditions
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Renal Transplantation, Uremia

Intervention / Treatment
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* Procedure: donor specific transfusion
* Drug: MMF, Bortezomib
* Procedure: drugs added according to the immuno condition of the recipients


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Uremia patient of any race that is greater than or equal to 18 years of age but less than 60 years old Recipients of a kidney from a certifiable relative donor 18-60 years of age Patient is willing and capable of giving written informed consent for study participation and able to participate in the study for 12 months Exclusion Criteria: Women who are pregnant, intend to become pregnant in the next 1 years, breastfeeding, or have a positive pregnancy test on enrollment or prior to study medication administration Patient with prior solid organ transplant or cell transplant (e.g. bone marrow or islet cell). Patient is deemed likely to have a second solid organ transplant or cell transplant (e.g. bone marrow or islet cell) in next 3 years Patient receiving a concurrent SOT (heart, liver, pancreas) or cell transplant (islet, bone marrow, stem cell) ABO incompatible donor recipient pair or CDC crossmatch positive transplant Sensitized patients (most recent anti-HLA Class I or II Panel Reactive Antibodies (PRA)>0% by a CDC-assay) or patients identified a high immunological risk by the transplant physician Donor with cardiac death (non-heart beating donor) Recipient CMV seronegative receiving a organ from a seropositive donor (CMV seromismatch) Donor OR Recipient are known hepatitis C antibody-positive or polymerase chain reaction (PCR) positive for hepatitis C Donors OR Recipient are known hepatitis B surface antigen-positive or PCR positive for hepatitis B AND recipient is HBV negative Patient and/or donors with known human immunodeficiency virus (HIV) infection Patient at risk for tuberculosis (TB) Current clinical, radiographic, or laboratory evidence of active or latent TB as determined by local standard of care History of active TB: Within the last 2 years, even if treated Greater than 2 years ago, unless there is documentation of adequate treatment according to locally accepted clinical practice Patient at risk of reactivation of TB precludes administration of conventional immunosuppression (as determined by investigator and based upon appropriate evaluation) Patient with any significant infection or other contraindication that would preclude transplant Patient with a history of hypercoaguable state Patient with a history of substance abuse (drugs or alcohol) within the past 6 months, or psychotic disorders that are not compatible with adequate study follow-up. Patient with active peptic ulcer disease (PUD), chronic diarrhea, or gastrointestinal malabsorption Patient with a history of cancer within the last 5 years (exception: non-melanoma skin cell cancers cured by local resection are permitted) Patient with a chest radiograph (no more than 2 months prior to randomization) consistent with an acute lung parenchymal process and malignancy Patient with a hypersensitivity to any study drugs Patient who have used any investigational drug within 30 days prior to the Day 1 visit . Patients with autoimmune disease or patient treated with immunosuppressive therapy (eg methotrexate, abatacept, etc) for indications such as autoimmune disease or patient with comorbidity to a degree that treatment with such agents is likely during the trial Prisoner or patient compulsorily detained (involuntarily incarcerated) for treatment or either a psychiatric or physical (e.g. infectious disease) illness

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Donor specific transfusion<br>Subjects with uremia will undergo donor specific transfusion before transplantation | Procedure: donor specific transfusion<br>* before transplantation,200mL of donor whole blood will be transfused to the recipient<br>|
| Experimental: Clonal deletion<br> | Drug: MMF, Bortezomib<br>* MMF and Bortezomib will be administered after donor specific transfusion<br>|
| Experimental: Drugs Added When Needed<br> | Procedure: drugs added according to the immuno condition of the recipients<br>* drugs (corticosteroid, MMF and/or CNI) will be added according to the recipients immuno event and donor specific antibody<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dosage of immunosuppressants | Effectiveness of clonal deletion on reducing the dosage of immunosuppressants (calcineurin inhibitor plus mycophenolate, azothioprine, or sirolimus). | one year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| immune event | Time to immune event (acute rejection or DSA); | 1 year | 
| DSA | Proportion of patients who become positive for donor specific HLA antibodies post transplant | 1 year | 
| DGF | Incidence of delayed graft function (defined as need for post-transplant dialysis) | 1 years | 
| Renal function | Change in renal function as determined by estimated glomerular filtration rate and proteinuria (>1g) at 1 year post transplant | 1 year | 
| Survival | Allograft Survival at 1 year post transplant | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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clonal deletion, kidney transplantation