Bortezomib in Rejection of Kidney Transplants

Study Overview
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Brief Summary
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The purpose of the study is to assess the efficacy of bortezomib, in association with steroids, plasma exchange, and polyclonal intravenous immunoglobulins, in the treatment of chronic antibody mediated rejection due to donor specific anti-HLA antibodies, in kidney transplant recipients

Detailed Description
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Chronic active antibody-mediated rejection (AMR) is considered as a main cause of late allograft losses in kidney transplant recipients. It is due to the occurrence of de novo donor-specific anti-HLA antibodies (DSA), i.e. antibodies synthetized by the recipient after transplantation against its transplant. There is currently to efficient treatment. The purpose of our study is to determine the efficacy of bortezomib, a proteasome inhibitor, in the treatment of chronic active antibody-mediated rejection, in association with steroids, plasma exchanges, and polyclonal intravenous immunoglobulins. Patients are recipients of a first or a second kidney transplant for more than 3 months. They display de novo DSA i.e. DSA not detected the day of transplantation and in pre-transplant sera.. They display signs of chronic active AMR on kidney biopsy i.e. a glomerulitis (g) + peritubular capillaritis (ptc) Banff score g+ptc ≥ 2, with or without severe chronic glomerulopathy (Banff score cg<3). Kidney biopsy may have been performed systematically or because of: : detection of de novo DSA , and /or proteinuria (> 0.5 g/24h) and /or slow graft dysfunction protocol biopsy Primary endpoint is a combined endpoint one year after inclusion, consisting of the stabilization of histological lesions on a new kidney biopsy (delta g+ptc ≤1 and delta cg < 1) and a decrease in DSA mean fluorescence intensity > 50%.

Official Title
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Treatment of Chronic Active Antibody-mediated Rejection With Bortezomib in Kidney Transplantation

Conditions
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Chronic Antibody-mediated Transplant Rejection

Intervention / Treatment
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* Drug: Bortezomib
* Drug: Plasma exchanges and intravenous immunoglobulins


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: recipients of a first or a second kidney transplant for more than 3 months age over 18 years with de novo donor specific antibodies (DSA), i.e. antibodies not detected the day of transplantation and in pre-transplant sera with histological lesions of chronic active antibody-mediated rejection (glomerulitis + peritubular capillaritis banff score and chronic glomerulopathy (g+ptc ≥ 2) on a graft biopsy performed because of renal function deterioration, proteinuria, detection of de novo DSA, or on a systematic biopsy written informed consent Given the teratogenic risks described in the SPCs of Velcade and Cellcept: Women of child bearing age must have a negative pregnancy test the day of the inclusion and should use at least one effective contraceptive method before start of medication during the treatment and during the study Men old enough to procreate have to use condoms during the treatment and at least 90 days after the last intake of the treatment during the study. Moreover, given SPCs of Cellcept, it is recommended that female partners to use an effective method of contraception treatment and for 90 days after the last mycophenolate intake by the partner male affiliated with social security health insurance patients with cell rejection lesions associated with chronic humoral rejection lesions active may be included in the study. This rejection can be treated with 3 boluses of 500 mg of methyl prednisolone prior to inclusion. Exclusion Criteria: patient with preformed DSA recipient of a 3rd or 4th kidney transplant recipient of a transplant combined with another not renal organ patient with a history of humoral acute rejection during the current transplantation estimated GFR below 20 ml/min/1,73m2 severe transplant glomerulopathy (cg score = 3) severe peripheral neuropathy, thrombopenia < 100 000 mm3 , neutropenia < 1000 mm3 and/or an uncontrolled evolutionary infection chronic active hepatitis B (positive HBs antigen or HBV DNA), positive chronic hepatitis C and/or known HIV infection allergy to bore or bortezomib or to one of the excipient hepatic failure, abnormal liver tests (bilirubin >3N, transaminases >3n), infiltrative pneumopathy, pericarditis risk of non-adherence to treatment or protocol inclusion in another clinical therapeutic trial

Ages Eligible for Study
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Minimum Age: 18 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: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Bortezomib<br>Five plasma exchanges, two cycles of bortezomib + dexamethasone, 4 courses of polyclonal intravenous immunoglobulins | Drug: Bortezomib<br>* Five plasma exchanges +0.1 g/kg of intravenous immunoglobulins at the end of each course two cycles of bortezomib (1.3 mg/m2 IV at day-1, day-4, day-8, day-11) + oral dexamethasone (20 mg po at day-1, day-4, day-8, day-11) four courses of polyclonal intravenous immunoglobulins every three weeks (2g/kg, the first two courses are performed simultaneously with the two bortezomib cycles)<br>* Other names: Velcade;|
| Active Comparator: Control<br>Five plasma exchanges, dexamethasone, 4 courses of polyclonal intravenous immunoglobulins | Drug: Plasma exchanges and intravenous immunoglobulins<br>* Five plasma exchanges +0.1 g/kg of intravenous immunoglobulins at the end of each course four courses of polyclonal intravenous immunoglobulins every three weeks (2g/kg) oral dexamethasone (20 mg po at day-1, day-3, day-5, day-7 of the two first intravenous immunoglobulins courses)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| histological lesions of humoral rejection and immunodominant donor specific antibody | Between inclusion biopsy and end of study biopsy delta g+ptc ≤1 and delta cg < 1 (Banff score of glomerulitis (g) capillaritis (ptc) and chronic allograft glomerulopathy (cg) Between inclusion and end of study, decrease in mean fluorescence intensity (MFI) of the immunodominant donor specific anti-HLA antibody (DSA with the highest MFI) by Luminex greater than 50% | one year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| histological lesions of humoral rejection | Between inclusion biopsy and end of study biopsy delta g+ptc ≤1 and delta cg < 1 (Banff score of glomerulitis (g) capillaritis (ptc) and chronic allograft glomerulopathy (cg) | one year | 
| immunodominant donor specific antibody | Between inclusion and end of study, decrease in mean fluorescence intensity (MFI) of the immunodominant donor specific anti-HLA antibody (DSA with the highest MFI) by Luminex greater than 50% | one year | 
| all donor specific antibodies at one year | Between inclusion and end of study, variation of the title of each DSA and the sum of the DSAs | one year | 
| all donor specific antibodies | Between inclusion and month-6, evolution in mean fluorescence intensity (MFI) of all donor specific anti-HLA antibodies by Luminex | 6 months | 
| Histological lesions | Description of all histological lesions observed at one-year biopsy according to the Banff classification and comparison with inclusion biopsy: acute cellular rejection, interstitial fibrosis and tubular atrophy, chronic vascular lesions (arteriolar hyalinosis, fibro-intimal thickening), chronic rejection (transplant glomerulopathy, fibroproliferative endarteritis) | one year | 
| renal function and proteinuria | Evolution between inclusion and end of study at one-year of serum creatinine, estimated GFR (MDRD formula), proteinuria output, proteinuria/creatinuria ratio | one year | 
| Safety of bortezomib in renal transplant recipients | Infectious and non-infectious adverse events occurring during study in the two arms of treatment | one year | 
| Patient and graft survival |  | one year | 
| T and B lymphocytes subsets with bortezomib | Flow cytometry study of T and B lymphocytes subsets at inclusion, month-6 and month-12 in patients treated with bortezomib | one year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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proteasome inhibitor,, Chronic antibody-mediated rejection,, transplant rejection, kidney transplantation,, anti-HLA antibodies,, immunosuppressive agents